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PRACTICAL TREATISE 



FRACTURES AND DISLOCATIONS. 



BY 
v 

FRANK HASTINGS HAMILTON, A.B., A.M., M.D, 

PROFESSOR OF THE PRINCIPLES OF SURGERY, MILITARY SURGERY AND HYGIENE, AND OF FRACTURES AND 

DISLOCATIONS IN BELLEVUE HOSPITAL MEDICAL COLLEGE J SURGEON TO BELLEVUE 

HOSPITAL AND TO THE CHARITY HOSPITAL, NEW YORK : 

PROFESSOR OF MILITARY SURGERY, ETC., IN THE LONG ISLAND COLLEGE HOSPITAL; AUTHOR OF 

A TREATISE ON MILITARY SURGERY. 



THIED EDITION, 
REVISED AND IMPROVED. 

ILLUSTRATED WITH 

TWO HUNDRED AND NINETY-FOUR WOOD-CUTS. 




PHILADELPHIA: 

HENET 0. LEA 
1866. 



v^ 



o\ 



*•*:, 



Entered according to trie Act of Congress, in the year 1866, by 

HENRY C. LEA, 

In the Office of the Clerk of the District Court of the United States in and for the 
Eastern District of Pennsylvania. 



PHILADELPHIA : 
COLLINS, PRINTER, 705 JAYNE STREET. 



< 






TO THE 

CIYIL AND MILITARY SURGEONS 

OF THE 

UNITED STATES OF AMERICA, 
BY WHOSE KINDNESS HE HAS BEEN PLACED UNDER MANY OBLIGATIONS; 

AND IN 
TESTIMONY OF HIS PERSONAL ESTEEM, 



%\h Wtthmt 



IS RESPECTFULLY DEDICATED 



THE AUTHOR. 



PREFACE TO THE THIRD EDITION. 



In the preparation of this edition the author has studied carefully 
the cases and observations which have found a record since the date 
of the last edition ; and in this labor he has been greatly assisted by 
that zealous student and thorough scholar, Dr. John Winslow, of this 
city. He has also added a considerable number of observations from 
his own private practice, but most of all from those ample fields of 
instruction, the Bellevue and Charity Hospitals, New York. 

Several changes have been made in the wood-cuts,, and a few have 
been added. The frequency with which even surgical writers confound 
epiphyseal separations with fractures, has determined the author to 
select from Gray's excellent treatise upon anatomy a number of illus- 
trations, indicating the centres of ossification and the subsequent de- 
velopment of bones. Two or three illustrations of fractures, found in 
the same treatise, have been substituted for the less satisfactory wood- 
cuts of previous editions. 

The chapter on " Gunshot Injuries" has been enlarged by the addi- 
tion of a few statistics obtained from the published records of the 
United States and Confederate armies. 

FKANK H. HAMILTON. 

64 Madison Avenue, N. Y. 
August, 1866. 



PREFACE TO THE FIRST EDITION. 



The English language does not at this moment contain a single com- 
plete treatise on Fractures and Dislocations. The two small volumes 
of Desault, and the one of Boyer, issued near the close of the last 
century, and translated into English early in this, may perhaps pro- 
perly enough have been regarded as complete treatises at the time 
of their publication, but they certainly cannot be so considered now. 
The several chapters on " Diseases and Injuries of the Bones," contained 
in the Lecons Orales of Dupuytren, translated in 1846, and the Trea- 
tise on Fractures in the Vicinity of the Joints, and on Certain Forms of 
Accidental and Congenital Dislocations, by Kobert Smith, are invaluable 
monographs, but neither of them claims to be anything more than a 
collection of occasional and miscellaneous papers. The writings of 
Amesbury and of Lonsdale relate only to fractures. Even the justly 
celebrated quarto of Sir Astley Cooper is no more than what its title 
plainly declares it to be, A Treatise on Dislocations and on Fractures of 
the Joints ; but since the announcement of the present volume, a trans- 
lation of Malgaigne's great and crowning work on Fractures and 
Dislocations has been commenced by Dr. Packard, of Philadelphia, 
and the first volume has been placed in the hands of the American 
profession. Should the remaining volume be rendered into English, 
the gap in our literature will be measurably filled. 

Under these circumstances I might scarcely have thought it worth 
while to continue my labors, already so near their completion, had it 
not seemed to me that Malgaigne, whose researches have been truly 
marvellous, had failed in some measure to give a just representation 
of the observations and improvements which have been made from 
time to time by my own countrymen. 

The contributions of American surgeons to this department had to 
be sought chiefly in medical journals, many of which have long been 
discontinued, and most of which were inaccessible to the great French 
writer. Even to an American, the labor of exhumation from archives 
hitherto almost unexplored has not been small ; and it is probable 



Vlll PREFACE TO THE FIRST EDITION. 

that many valuable papers have been overlooked; indeed it is impos- 
sible that it should be otherwise. 

I am free to say, also, that I have been encouraged by a hope that 
my own personal experience, obtained during many years of public 
and private service, might be of some value to my contemporaries. 

Yery little space has been devoted to what is now only historical, 
except so far as w r as necessary to correct certain time-consecrated 
errors, or to confirm and illustrate the practice of the present day ; 
but, by a pretty full report of characteristic examples, selected from 
more than one thousand cases already published by myself, by copious 
references to the examples recorded by others, and by a careful exclu- 
sion of whatever has not been confirmed by experience or established 
by dissection, I have endeavored to make this treatise useful both to 
the student and practical man, and a reliable exponent of the present 
state of our art upon those subjects of which it treats. 

In order to render the description of the various forms of apparatus 
employed in the treatment of fractures more intelligible, and to avoid 
the necessity of lengthened explanations, a large number of illustra- 
tions have been introduced, more, perhaps, than might be thought 
necessary, especially as in several instances the apparel which is figured 
is not that which is recommended by the author. It is believed, bow- 
ever, that by a study of the principal forms of approved dressings the 
reader will be better prepared for the exigencies of practice; and that 
by the simultaneous presentation of those w r hich are not approved, he 
will be saved from a wasteful expenditure of his time in the contriv- 
ance of useless apparatus. It is not in the discovery and multiplica- 
tion of mechanical expedients that the surgeon of this day declares his 
superiority, so much as in the skilful and judicious employment of 
those which are already invented. 

The author desires to acknowledge his indebtedness to very many 
of his professional brethren, throughout the United States, for the 
promptness w T ith which they have responded from time to time to his 
inquiries, and for the generosity with which they have opened their 
pathological collections and placed valuable specimens at his disposal. 

He wishes also to express his special obligations to Dr. J. R. Lothrop, 
of this city, w r ho has kindly aided him in revising most of the proof 
sheets as they have been issued from the press. 

FRAXK H. HAMILTON. 

Buffalo, N. Y., December, 1859. 



CONTENTS. 



PART I. 

FK AC TUBES. 
CHAPTER I. 

PAGE 

General Division of Fractures ....... 27 

CHAPTER II. 

General Etiology of Fractures . . . . . . .29 

CHAPTER III. 

General Semeiology and Diagnosis ...... 33 

CHAPTER IY. 

Repair of Broken Bones . . . . . . '. .37 

CHAPTER V. 

General Treatment of Fractures ...... 44 

CHAPTER VI. 

Delayed Union and Non-Union of Broken Bones . . . .61 

CHAPTER VII. 

Bending, Partial Fractures, and Fissures of the Long Bones . ... 72 

§ 1. Bending of the Long Bones . . . . . .72 

§ 2. Partial fracture of the Long Bones . . . . .16 

§ 3. Fissures . . . . . . 85 

CHAPTER VIII. 

Fractures of the Nose ........ 90 

§ 1. Ossa Nasi ........ 90 

§ 2. Fractures and Displacements of the Septum Narium . . .95 



CONTEXTS. 



CHAPTER IX 



Fractures of the Malar Bo>~e 



page 
98 



CHAPTER X. 

Fractures of tee Upper Maxillary Boxes 



101 



CHAPTER XI, 

Fractures of the Zygomatic Arch 



106 



CHAPTER XII. 



Fractures of the Lower Jaw 



109 



CHAPTER XIII. 

Fractures of the Hyoid Bone .... 



134 



CHAPTER XI Y. 

Fractures of the Cartilages of the Laryxx . 
§ 1. Thyroid Cartilage 
§ 2. Thyroid and Cricoid Cartilages 
§ 3. Cricoid Cartilage 

CHAPTER XY 

Fractures of the Vertebra 

§ 1. Fractures of the Spinous Processes . 
§ 2. Fractures of the Transverse Processes 
§ 3. Fractures of the Vertebral Arches 
§ 4. Fractures of the Bodies of the Vertebrae 

1. Fractures of the Bodies of the Lumbar Vertebrae 

2. Fractures of the Bodies of the Dorsal Vertebrae . 

3. Fractures of the Bodies of the five lower Cervical Vertebrae 

4. Treatment of Fractures of the Bodies of the Vertebrae . 
§ 5. Fractures of the Axis ...... 

§ 6. Fractures of the Atlas ...... 

§ 7. Fractures of the first two Cervical Vertebrae (Atlas and Axis) at the 

same time ........ 



CHAPTER XYI. 



Fractures of the Sternum 



139 
139 
139 
141 



143 

143 
145 
146 
152 
153 
155 
15 o 
158 
161 
163 

164 



165 



CHAPTER XVII. 

Fractures of the Ribs and their Cartilages . 

§ 1. Fractures of the Ribs . . . . • 

§ 2. Fractures of the Cartilages of the Ribs 

CHAPTER XVIII. 



171 
171 
176 



Fractures of the Clavicle 



177 



CONTEXTS. 



XI 



CHAPTER XIX. 

Fractures of the Scapula .... 

§ 1. Fractures of the Body of the Scapula 
§ 2. Fractures of the Neck of the Scapula 
§ 3. Fractures of the Acromion Process 
§ 4. Fractures of the Coracoid Process 



PAGE 

200 
200 
205 
206 
209 



CHAPTER XX. 

Fractures of the Humerus ....... 212 

§ 1. Fractures of the Head and Anatomical Neck .... 213 

§ 2. Fractures through the Tubercles ..... 217 

§ 3. Longitudinal Fractures of the Head and Neck ; or Splitting off of the 

Greater Tubercle ....... 218 

§ 4. Fractures through the Surgical Neck (including Separations at the 

Upper Epiphyses) ....... 220 

§ 5. Fractures of the Shaft below the Surgical Neck, and above the Base 

of the Condyles ....... 232 

§ 6. Fractures at the Base of the Condyles (including Separations of the 

Lower Epiphysis) ....... 242 

§ 7. Fractures at the Base of the Condyles, complicated with Fracture 

between the Condyles, extending into the Joint . . . 250 

§ 8. Fractures of the Internal Epicondyle ..... 253 

§ 9. Fractures of the External Epicondyle ..... 257 

§ 10. Fractures of the Internal Condyle ..... 258 

§ 11. Fractures of the External Condyle ..... 260 



CHAPTER XXI 



Fractures of the Radius 



264 



CHAPTER XXII 



Fractures of the Ulna . 
§ 1. Shaft of the Ulna 
§ 2. Coronoid Process of the Ulna . 
§ 3. Fractures of the Olecranon Process 



293 
293 
297 
306 



CHAPTER XXIII. 

Fractures of the Radius and Ulna 



314 



CHAPTER XXIY 

Fractures of the Carpal Bones 



323 



CHAPTER XX Y. 

Fractures of the Metacarpal Bones . 



324 



CHAPTER XXYI. 



Fractures of the Fingers 



327 



Xll 



CONTEXTS. 



CHAPTER XXYII. 

Fractures of the Pelvis, and Traumatic Separations at its Symphyses 

§ 1. Pubes . 

§ 2. Ischium 

§ 3. Ilium . 

§ 4. Acetabulum 

§ 5. Sacrum 

§ 6. Coccyx 

CHAPTER XXVIII. 

Fractures of the Femur ....... 

§ 1. Neck of the Femur .'...... 

(a.) Neck of the Femur within the Capsule 

(b.) Neck of the Femur without the Capsule 

(c.) Fractures of the Neck partly within and partly without the 
Capsule ....... 

\ 2. Fractures through the Trochanter Major and Base of the Neck of the 

Femur ........ 

§ 3. Fractures of the Epiphysis of the Trochanter Major . 

§ 4. Fractures of the Shaft of the Femur ..... 

§ 5. Fractures of the Condyles ...... 

(a.) Fractures of the External Condyle .... 

(b.) Fractures of the Internal Condyle .... 

(c.) Fractures between the Condyles and across the Base . 



PAGE 

330 
331 
334 
336 
339 
345 
347 



347 

343 
349 

353 

390 

390 
391 
393 
437 
437 
433 
440 



CHAPTER XXIX. 



Fractures of the Patella 



442 



CHAPTER XXX 



Fractures of the Tibia . 



453 



CHAPTER XXXI. 

Fractures of the Fibula .... 

CHAPTER XXXII. 

Fractures of the Tibia and Fibula 



457 



461 



CHAPTER XXXIII. 

Fractures of the Tarsal Bones 



450 



CHAPTER XXXIY. 

Fractures of the Metatarsal Bones 



455 



CHAPTER XXXY. 

Fractures of the Phalanges of the Toes 



457 



CHAPTER XXXVI 



Gunshot Fractures 



4S7 



CONTEXTS. 



Xlll 



PAET II. 



DISLOCATIONS, 
CHAPTER I. 



General Considerations 

§ 1. General Division and Nomenclature 

§ 2. General Predisposing Causes 

§ 3. Direct or Exciting Causes 

§ 4. General Symptoms 

§ 5. Pathology 

§ 6. General Prognosis 

§ 7. General Treatment 



PAGE 

497 
497 
498 
499 
499 
501 
§02 
502 



CHAPTER II. 

Dislocations of the Lower Jaw ...... 505 

§ 1. Double or Bilateral Dislocations ..... 505 

§ 2. Single or Unilateral Dislocations . . . . . 509 

§3. Conditions of the Jaw simulating Luxations .... 510 

CHAPTER III. 

Dislocations of the Spine ....... 512 

§ 1. Dislocations of the Lumbar Vertebrae ..... 513 

§2. Dislocations of the Dorsal Vertebrae ..... 514 

§ 3. Dislocations of the Six Lower Cervical Vertebrae . . . 517 

§ 4. Dislocations of the Atlas . . . . . 524 

§ 5. Dislocations of the Head upon the Atlas, or Occipito-Atloidean Dis- 
locations . . . . . . . . 525 



CHAPTER IY. 

Dislocations of the Ribs . , . . . . . 526 

§ 1. Dislocations of the Ribs from the Vertebrae . . . . 526 

§ 2. Dislocations of the Ribs from the Sternum . . . 527 

§ 3. Dislocations of one Cartilage upon another . . ... 528 

CHAPTER Y. 

Dislocations of the Clavicle ....... 529 

§ 1. Dislocations forwards at the Sternal End .... 529 

§ 2. Dislocations of the Sternal End of the Clavicle Upwards . . 533 

§ 3. Dislocations of the Sternal End of the Clavicle Backwards . . 534 

§ 4. Dislocations of the Acromial End of the Clavicle Upwards . . 536 

§ 5. Dislocations of the Acromial End of the Clavicle Downwards . 541 
§ 6. Dislocations of the Acromial End of the Clavicle under the Coracoid 

Process ........ 542 



XIV CONTEXTS. 



CHAPTER VI. 

PAGE 

Dislocations of the Shoulder (Humerus at its upper Extremity) . . 543 

§ 1. Dislocations of the Shoulder Downwards (Subglenoid) . . 544 

Dislocation, with Fracture of the Humerus near its Upper End . 568 

§ 2. Dislocations of the Humerus Forwards (Subcoracoid and Subclavicular) 570 

§ 3. Dislocations of the Humerus Backwards (Subspinous) . . 575 

§ 4. Partial Dislocations of the Humerus . . . . . 579 

CHAPTER VII. 

Dislocations of the Head of the Radius ..... 582 

§ 1. Dislocations of the Head of the Radius Forwards . . . 582 

§ 2. Dislocations of the Head of the Radius Backwards . . . 587 

§ 3. Dislocations of the Head of the Radius Outwards . . . 589 

CHAPTER VIII. 

Dislocations of the Upper End of the Ulna Backwards . . . 590 

CHAPTER IX. 

Dislocations of the Radius and Ulna (Forearm at the Elbow-Joint) . 591 

§ 1. Dislocations of the Radius and Ulna Backwards . . . bdl 

§ 2. Dislocations of the Radius and Ulna Outwards (to the Radial Side) 601 

§ 3. Dislocations of the Radius and Ulna Inwards (to the Ulnar Side) . 605 

§ 4. Dislocations of the Radius and Ulna Forwards . . . 608 

CHAPTER X. 

Dislocations of the Wrist (Radio-Carpal Articulation) . . . 609 

§ 1. Dislocations of the Carpal Bones Backwards . . . 611 

§ 2. Dislocations of the Carpal Bones Forwards .... 614 

CHAPTER XI. 

Dislocations of the Lower End of the Ulna (Inferior-Radio Ulnar Articu- 
lation) ......... 615 

§ 1. Dislocations of the Lower End of the Ulna Backwards . . 615 
§ 2. Dislocations of the Lower End of the Ulna Forwards . . .616 

CHAPTER XII. 

Dislocations of the Carpal Bones (among themselves) . . . 617 

CHAPTER XIII. 

Dislocations of the Metacarpal Bones (at the Carpo-Metacarpal Articula- 
tions) .......... 619 

CHAPTER XIV. 

Dislocations of the First Phalanges of the Thumb and Fingers (at the 

Metacarpo-Phalangeal Articulations) ..... 621 

§ 1. Dislocations of the First Phalanx of the Thumb Backwards . 621 

§ 2. Dislocations of the First Phalanx of the Thumb Forwards . . 629 

§ 3. Dislocations of the First Phalanx of the Fingers . . . 630 



CONTENTS. 



XV 



CHAPTER XV. 

PAGE 

Dislocations of the Second and Third Phalanges op the Thumb and Fingers 631 



CHAPTER XVI. 

Dislocations of the Thigh (Coxo-Femoral) ..... 
§ 1. Dislocations Upwards and Backwards on the Dorsum Ilii 
§ 2. Dislocations Upwards and Backwards into the Great Ischiatic Notch 
§ 3. Dislocations Downwards and Forwards into the Foramen Thyroideum 
§ 4. Dislocations Upwards and Forwards upon the Pubes 
§ 5. Anomalous Dislocations, or Dislocations which do not properly belong 
to either of the four principal divisions before described 

1. Dislocations directly Upwards ..... 

2. Dislocations Downwards and Backwards upon the Posterior Part 

of the Body of the Ischium, between its Tuberosity and its 
Spine ........ 

3. Dislocations Downwards and Backwards into the Lesser or Lower 

Ischiatic Notch .... 

4. Dislocations directly Downwards 

5. Dislocations Forwards into the Perineum 
§ 6. Ancient Dislocations of the Femur 
§ 7. Partial Dislocations of the Femur 
§ 8. Coxo-Femoral Dislocations, complicated with Fracture of the Femur 

Voluntary Dislocations of the Femur .... 



§9. 



634 
636 
659 
665 



673 

673 



674 

675 
676 
677 

678 
681 

682 
685 



CHAPTER XVII. 

Dislocations of the Patella 

§ 1. Dislocations of the Patella Outwards 
§ 2. Dislocations of the Patella Inwards . 
§ 3. Dislocations of the Patella upon its Axis 
§ 4. Dislocations of the Patella Upwards . 



686 
686 
689 
689 
691 



CHAPTER XVIII. 

Dislocations of the Head of the Tibia . 

§ 1. Dislocations of the Head of the Tibia Backwards 

§ 2. Dislocations of the Head of the Tibia Forwards 

§ 3. Dislocations of the Head of the Tibia Outwards 

§ 4. Dislocations of the Head of the Tibia Inwards 

§ 5. Dislocations of the Head of the Tibia Backwards and Outwards 

§ 6. Internal Derangement of the Knee-Joint . . . 



692 
693 
695 
697 
698 
699 
700 



CHAPTER XIX. 

Dislocations of the Lower End of the Tibia 

§ 1. Dislocations of the Lower End of the Tibia Inwards 
§ 2. Dislocations of the Lower End of the Tibia Outwards 
§ 3. Dislocations of the Lower End of the Tibia Forwards 
§ 4. Dislocations of the Lower End of the Tibia Backwards 



702 
702 
707 
708 
712 



XVI 



CONTEXTS. 



CHAPTER XX. 

Dislocations of the Upper End of the Fibula . 

§ 1. Dislocations of the Upper End of the Fibula Forwards 
§ 2. Dislocations of the Upper End of the Fibula Backwards 

CHAPTER XXI. 

Dislocations of the Inferior Peroneo-Tibial Articulations . 



PAGE 

713 
713 
714 



'15 



CHAPTER XXII. 

Tarsal Luxations .... 

§ 1. Dislocations of the Astragalus 
§ 2. Astragalo-Calcaneo-Scaphoid Dislocations 
§ 3. Dislocations of the Calcaneum 
§ 4. Middle Tarsal Dislocations 
§ 5. Dislocations of the Os Cuboides 
§ 6. Dislocations of the Os Scaphoides 
§ 7. Dislocations of the Cuneiform Bones . 



715 

715 
722 
724 
724 
725 
725 

m 



CHAPTER XXIII 

Dislocations of the Metatarsal Bones 



727 



CHAPTER XXIY. 

Dislocations of the Phalanges of the Toes . . . 



730 



CHAPTER XXY. 

Compound Dislocations of the Long Bones » 731 

CHAPTER XXYI. 

Congenital Dislocations ....... 746 

§ 1. General Observations and History ..... 746 

§ 2. Etiology . . . . # . . . .748 

§ 3. Congenital Dislocations of the Inferior Maxilla . . . 749 

§ 4. Congenital Dislocations of the Spine . . . . 752 

§ 5. Congenital Dislocations of the Pelvic Bones .... 753 

§ 6. Congenital Dislocations of the Sternum .... 753 

§ 7. Congenital Dislocations of the Clavicle .... 754 

§ 8. Congenital Dislocations of the Shoulder (Upper End of the Humerus) 754 

§ 9. Congenital Dislocations of the Radius and Ulna Backwards . 758 

§ 10. Congenital Dislocations of the Head of the Radius . . 758 

§ 11. Congenital Dislocations of the Wrist .... 759 

§ 12. Congenital Dislocations of the Fingers .... 760 

§ 13. Congenital Dislocations of the Hip ..... 760 

§ 14. Congenital Dislocations of the Patella .... 766 

§ 15. Congenital Dislocations of the Knee .... 767 

§ 16. Congenital Dislocations of the Tarsal Bones . . . 770 

§ 17. Congenital Dislocations of the Toes . . . . 770 



LIST OF ILLUSTRATIONS 



FRACTURES. 

FIG. 

1. Perforating and longitudinal fracture 

2. Impacted extra-capsular fracture of neck of femur 

3. Union of fracture with the fragments widely separated 

4. Fracture united with, an oblique callus 

5. Application of the roller, by circular and reversed turns 

6. Many-tailed bandage .... 

7. Application of the many-tailed bandage . 

8. Bandage of Scultetus . 

9. Wood and leather splint .... 

10. Starch bandage applied for a broken thigh 

11. Seutin's pliers ..... 

12. Opening the apparatus with Seutin's pliers 

13. Apparatus immobile, applied over a compound fracture 

14. Clavicle, united by ligamentous bands 

15. Hudson's splint, ununited fracture 

16. Physick's first case, treated by seton — after 28 years 

17. Dieffenbach's drill for ununited fracture . 

18. Brainard's perforator for ununited fracture 

19. Bone drill ...... 

20. Gaillard's instrument for ununited fractures 

21. Fergusson's case of permanent bending without fracture 

22. Partial fracture of the femur without restoration of the bone to its 

form . 

23. Partial fracture of the clavicle without spontaneous restoration 

24. Partial fracture after union is consummated 

25. Fracture of the lower jaw . 

26. Beans' maxillary articulator 

27. Beans' apparatus for broken jaw, applied 

28. Gibson's bandage for a fractured jaw 

29. Barton's bandage for a fractured jaw 

30. Four-tailed bandage or sling for the lower jaw 

31. The author's apparatus for a broken jaw 

32. Fracture of the spinous process 

33. Fracture of the vertebral arches . 

34. Oblique fracture of the body of a vertebra 

35. Key's case of fracture of the first lumbar vertebra 

2 



natural 



PAGE 

28 
28 
41 
41 
46 
46 
47 
47 
51 
54 
55 
56 
57 
63 
66 
67 
68 
69 
69 
71 
75 

81 
81 
82 
110 
126 
126 
130 
130 
131 
132 
144 
146 
153 
155 



XV111 



LIST OF ILLUSTRATIONS. 



FIG, 

36. 
37. 
38. 
39. 
40. 
41. 

42. 
43. 
44. 

45. 
46. 
47. 
48. 
49. 
50. 
51. 
52. 
53. 
54. 
55. 
56, 

58. 
59. 
60. 
61. 
62. 
63. 
64. 
65. 
66. 
67. 



71. 

72. 
73. 

74. 
75. 
76. 
77. 
78. 
79. 
80. 
81. 
82. 
83. 



Parker's case of fracture of the odontoid process of the axis 

Development of sternum ..... 

Fracture of ribs, with lateral union 

Oblique fracture, near the middle of the clavicle 

Fracture of the clavicle outside of the trapezoid ligament 

Complete oblique fracture of the clavicle at the outer end of the inner 

two-thirds ...... 

Comminuted fracture of the clavicle united 
Velpeau's dressing for a fractured clavicle 
Figure-of-8 bandage, for a broken clavicle 
Keckerley's apparatus for a fractured clavicle 
Bartlett's apparatus for a fractured clavicle 
Fox's apparatus for a fractured clavicle . 
The author's apparatus for a fractured clavicle . 
Fracture of angle of scapula .... 

Fractures of the body and acromion process of the scapula 

Comminuted fracture of the glenoid cavity 

Fracture of the neck of the scapula 

Scapula with epiphyses ..... 

Fracture of the coracoid process .... 

Fracture at the anatomical neck of the humerus . 

57. Pope's specimen of supposed fracture at the anatomical neck of the 

humerus, and reversion of the head — front and side views 
Humerus with epiphyses . 
Fracture of surgical neck of humerus 
Welch's shoulder splint ..... 
Lonsdale's apparatus for extension, in fractures of the humerus 
Fracture of the humerus at the base of the condyles 
Separation of lower epiphyses 

Physick's elbow splint ..... 
Kirkbride's elbow splint ..... 
Rose's arm and forearm splint . . 

Welch's arm and forearm splint .... 
Bond's elbow splint ..... 

The author's elbow splint ..... 
Fracture at the base of the condyles of the humerus, and between the 

condyles ....... 

Fracture of internal epicondyle of the humerus . 
Fracture of external epicondyle .... 

Fracture of the internal condyle of the humerus 
Fracture of external condyle .... 

Mutter's specimen of fracture of the neck of the radius . 
Fractures of head of l'adius .... 

Fracture of the shaft of the radius 

Colles' fracture — radius near its lower end 

Bigelow's case of comminuted fracture of the lower end of the radius 

Kelaton's splint for fracture of the radius near its lower end 

Bond's splint for fracture of the lower end of the radius 

Hay's splint for fracture of the lower end of the radius . 

E. P. Smith's splint for fractures of the lower end of the radius — front 

view ......... 



282 



LIST OF ILLUSTRATIONS. 



XIX 



FIG. 

84. Same as above — back view ..... 

85. Shrady's splint for Colles' fracture .... 

86. The author's splint for fracture near the lower end of tlie radius 

ST. The author's dressing for a fracture of the radius near its lower end 
complete ....... 

88. Radius, with epiphyses ...... 

89. Fracture of the shaft of the ulna .... 

90. Fracture of the coronoid process of the ulna 

91. Ulna, with epiphyses ...... 

92. Fracture of the olecranon process at its base 

93. Olecranon process united by ligament .... 

94. Sir Astley Cooper's method of dressing a fracture of the olecranon process 

95. The author's splint for a fracture of the olecranon process 

96. The same applied ...... 

97. Fracture of the radius and ulna in the middle third 

98. Fracture of the radius and ulna in the lower third 

99. Radius and ulna united with displacement 

100. Development of os innominatum 

101. Clark's case of comminuted fracture of the pelvis 

102. Development of femur ...... 

103. Fracture of the neck of the femur, within the capsule . 

104. Impacted fracture of the neck of the femur, within the capsule 

105. Neck of unsound femur — case of Mr. S., reported by Mussey . 

106. The same — vertical section ..... 

107. Sound femur of Mr. S. . 

108. Neck of unsound femur ; case of Mr. N., reported by Dr. Mussey 

109. Same as above — vertical section ..... 

110. Sound femur of Mr. N. . 

111. Neck of unsound femur ; case of Mrs. M., reported by Dr. Mussey 

112. The same — vertical section ..... 

113. Vertical section of the neck of the femur, capsule and acetabulum — case 

of Mrs. Wakelee ...... 

114. Section of the head and neck of the sound femur of an adult 

115. Chronic rheumatic arthritis, in hip-joint 

116. Crosby's specimen of fracture of neck of femur within the capsule— 

ununited ....... 

117. Mayo's specimen of fracture of the neck of the femur within the cap 

sule, united by ligament ..... 

118. Gibson's Modification of Hagedorn's thigh splints 

119. Gibson's splint applied ...... 

120. 121, 122. Impacted, extra-capsular fracture 

123. Fracture of the neck of the femur .... 

124. Extra-capsular fracture of the neck of the femur — ununited . 

125. Extra-capsular fracture of the neck of the femur— with excess of callus 

126. The same — vertical section ...... 

127. Extra-capsular fracture of the neck of the femur — united with irregular 

callus ........ 

128. Miller's splint for extra-capsular fractures 

129. Sir Astley Cooper's mode of treating fractures of the trochanter major 

130. Fracture of the femur at the base of the condyles 

131. Physick's thigh splint ...... 



PAGE 

282 
282 
2S6 

287 
292 
293 
298 
301 
307 
309 
311 
312 
312 
314 
315 
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331 
333 
348 
349 
351 
360 
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361 
363 
363 
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373 
375 
375 

379 

379 

380 
380 

384 
386 
387 
3S8 
388 

388 
3S9 
393 
394 

402 



XX 



LIST OF ILLUSTRATIONS 



FIG. 

132. Liston's dressing of fractured femur with, a straight splint 

133. Double inclined plane employed in Middlesex Hospital, London 

134. Amesbury's double inclined plane .... 

135. Amesbury's splint, applied ..... 

136. Boyer's thigh splint applied ..... 

137. Nathan R. Smith's suspending thigh splint, or double inclined plane 

138. Nott's double inclined plane ..... 

139. N. R. Smith's anterior splint ..... 

140. N. R. Smith's anterior splint, applied .... 

141. Burge's fracture bed and thigh splint .... 

142. The same in use ....... 

143. Neill's straight thigh splint, for extension and counter-extension 

144. Flagg's thigh apparatus — employed in the Massachusetts General Hos 

pital. Pelvic belt and perineal straps 

145. Same — footpiece and screw 

146. Same — lateral view of the apparatus, without the belt 

147. Same — front view, with folded sheets laid across 

148. Same — apparatus applied, front view 

149. Same — apparatus applied, side view 

150. Same — mode of applying adhesive plasters to leg 

151. Same — mode of making extension by adhesive plasters 

152. Same — perineal band secured with a padlock 

153. Sanborn's thigh splint .... 

154. Gurdon Buck's fracture apparatus 

155. Horner's thigh splint 

156. Joseph Hartshorne's thigh splint . . . 

157. George F. Shrady's thigh splint . 

158. Chapin's thigh apparatus 

159. Gilbert's thigh apparatus — mode of making extension and counter ex 

tension with adhesive straps . 

160. Same — applied in a case of fracture of both thighs 

161. H. L. Hodge's method of extension in fractures of the femur 

162. Lente's long, straight thigh splint, modified by Tiemann 

163. Lente's thigh splint, applied .... 

164. The author's single straight thigh splint, for children or adults 

165. The author's single straight thigh splint for children, or the straight 

splint in its simplest and elementary form 

166. The author's double straight thigh splint, for children or adults 

167. 168, 169. The same — endless screw ; front, side, and end views 

170. The same — front removed, showing the interior 

171. Fracture- of femur just below trochanter minor . 

172. Jenk's fracture bed 

173. Daniels' fracture bed — descriptive diagram 

174. The same — complete 

175. The same — in use . 

176. Crosby's specimen of fracture of the external condyle of the femur 

177. Sir Astley Cooper's case of fracture of the external condyle of the femur 

178. Transverse fracture of the patella . 

179. Comminuted fracture of the patella 

180. Transverse fracture of the patella — exhibiting the relations of the mus- 

cles to the fracture . . . . . . 



443 



LIST OF ILLUSTRATIONS. 



XXI 



FIG. 

181. Fragments "of a broken patella separated by flexion of the knee 
JS2. Upper fragment of a broken patella drawn up very much by the action 
of the quadriceps femoris ..... 

183. The author's mode of dressing a fractured patella 

184. Wood's apparatus for a fractured patella 
1S5. Dorsey's patella splint ...... 

186. Sir Astley Cooper's method for broken patella by circular and parallel 

tapes ........ 

187. Sir Astley Cooper's method by a leather band and couuter-strap 

188. Lonsdale's apparatus for fractured patella 

189. Development of tibia ...... 

190. Development of fibula ...... 

191. Fracture of the fibula near its lower end 

192. Dupuytren's splint for broken fibula — modified . 

193. Same — improperly applied 

194. Dupuytren's splint, as originally made and applied by himself 

195. Compound and comminuted fracture of the leg . 

196. Long splint for fracture of the leg in Pott's position 

197. Hutchinson's splint for extension in fractures of the leg 

198. Neill's apparatus for fractures of the leg requiring extension and counter 

extension . . . . . . 

199. Neill's apparatus for compound fractures of the leg 

200. Gilbert's fracture box . . . . . . 

201. Crandall's apparatus for fractures of the leg requiring extension and 

counter-extension — side view . . . . 

202. Same. Posterior view of the lower section 

203. Same. Posterior view of the entire apparatus . 

204. Immovable apparatus — applied to the leg . 

205. Liston's double-inclined plane, applied to the leg in a case of compoun 

fracture ........ 

206. Bauer's wire splints, for the leg ..... 

207. Swing box, for fractures of the leg ... . 

208. Salter's cradle for fractures of the leg .... 

209. Fracture box for the leg, with movable sides 

210. Wire rack, for fracture of the leg .... 

211. 212. Malgaigne's apparatus for certain oblique fractures of the leg 
213. Apparatus for fracture of the tuberosity of the calcaneum 



PAGE 

444 

445 
448 
450 
450 

451 

451 
452 
453 
457 
458 
459 
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463 
'467 
471 

471 

472 
472 

47 
473 
473 
475 

476 
476 

477 
477 
478 
478 
478, 479 
485 



DISLOCATIONS. 

214. Clove hitch . 

215. Compound pulleys and ring 

216. 217. Double dislocation of the inferior maxilla . 

218. Ayres' case of bilateral dislocation of the fifth cervical vertebra 

219. Dislocation of the sternal end of the clavicle, forwards 

220. Sir Astley Cooper's apparatus for dislocated clavicle 

221. Dislocation of the acromial end of the clavicle, upward and outward 

222. Mayor's apparatus for dislocated clavicle 

223. 224. Dislocation of the shoulder downwards into the axilla 
225. New socket, in an ancient luxation of the shoulder downwards 



504 

504 
507, 508 
523 
530 
532 
537 
540 
545, 546 
552 



XX11 



LIST OF ILLUSTRATIONS, 



FIG. 

226. N. R. Smith's method of reducing a dislocation of the shoulder 

227. La Mothe's method of reducing a dislocation of the shoulder — modified 

228. Sir Astley Cooper's method, with the heel in the axilla 

229. Sir Astley Cooper's method, with the knee in the axilla 

230. Iron knob employed by Skey, instead of the heel 

231. Skey's method in dislocations of the shoulder 

232. Sir Astley Cooper's method, by means of pulleys 

233. Subcoracoid dislocation of the humerus .... 

234. Subclavicular dislocation of humerus .... 

235. Subcoracoid dislocation . . . 

236. Subspinous dislocation of the humerus .... 

237. Displacement of the long head of the biceps 

238. Dislocation of the head of the radius forwards — anatomical relations 

239. Dislocation of the head of the radius forwards . 

240. Dislocation of the head of the radius backwards 

241. Dislocation of the upper end of the ulna backwards 

242. Dislocation of the radius and ulna backwards . 

243. Sir Astley Cooper's method in dislocation of the radius and ulna back- 

wards ........ 

244. Most frequent form of incomplete outward dislocation of the forearm 

245. Most frequent form of incomplete inward dislocation of the forearm 

246. Canton's case, dislocation of the radius and ulna forwards 

247. 248. Dislocation of the carpal bones backwards . 

249, 250. Dislocation of the carpal bones forwards — skeleton 

251. Dislocation of the first phalanx of the thumb backwards 

252. Clove hitch ....... 

253. Sir Astley Cooper's method of reducing dislocations of the thumb by 

the pulleys . . . . ... 

254. 255. Levis's instrument for reduction of the phalanges . 

256. Indian "puzzle" — employed in the reduction of dislocations of small 

joints ........ 

257. Backward dislocation of the first phalanx of the index finger — reduction 

by extension ....... 

258. Dislocation of the second phalanx backwards . 

259. Dislocation of the second phalanx forwards 

260. 261. Dislocation of the femur upon the dorsum ilii 

262. Nathan Smith's method of reduction of a dislocation of the head of the 

femur upon the dorsum ilii, by manipulation . 

263. Hippocrates' mode of reducing dislocations of the hip by manipulation 

264. Reduction of a dislocation upon the dorsum ilii by pulleys 

265. Reduction of a dislocation upon the dorsum ilii by a twisted rope 

266. Jarvis's adjuster — applied in dislocation of the hip 

267. Bloxham's dislocation tourniquet — applied for reduction of a dislocation 

of the femur upon the pubes ...... 

268. Reduction of a dislocation of the femur upon the dorsum ilii, by pulleys 

269. 270. Dislocation of the femur upwards and backwards into the great 

ischiatic notch . . • . 

271. Reduction of a dislocation into the great ischiatic notch, by pulleys 

272, 273. Dislocation of the femur downwards and forwards into the foramen 

thyroideum . . . . . . 



PAGE 

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558 
559 
560 
560 
561 
562 
571 
572 
573 
577 
580 
583 
584 
589 
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596 
601 
606 
608 
612, 613 
614, 615 
622 
624 

625 
627 

628 

630 

632 

632 

637, 639 

645 
647 
648 
649 
650 

650 
657 

659, 660 
663 

6Q6 



LIST OF ILLUSTRATIONS. 



XX111 



FIG. 

274. Sir Astley Cooper's mode of reducing recent luxations of the femur into 

the foramen thyroideuni ...... 

275. Specimen of dislocation upon the pubes, in St. Thomases Hospital 

276. Dislocation upwards and forwards upon the pubes 

277. Reduction of dislocation upon the pubes by extension 

278. Dislocation of the patella outwards 

279. Dislocation of the patella inwards 

280. Dislocation of the head of the tibia backwards 

281. Dislocation of the head of the tibia forwards 

282. Subluxation of the head of the tibia outwards 

283. Subluxation of the head of the tibia inwards 

284. 2S5. Dislocation of the lower end of the tibia inwards 

286. Reduction of a dislocation of the ankle by pulleys 

287. Dislocation of the lower end of the tibia outwards 

288. 289. Dislocations of the lower end of the tibia forwards 
290, 291. Dislocation of the lower end of the tibia backwards 

292. Dislocation of the astragalus outwards — anatomical relations 

293. Simple dislocation of the astragalus outwards . 

294. Compound dislocation of the astragalus inwards 



PAGE 

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693 
695 
697 
698 
703, 704 
705 
707 
710 
712 
716 
717 
717 



PART I 



FRACTURES 



FRACTURES. 



CHAPTEE I. 

GENERAL DIVISION OF FRACTURES. 

Fractures are divided into Complete and Incomplete, Simple, 
Comminuted, Compound, and Complicated. 

A Complete fracture is one in which the line of division completely 
traverses the bone. 

An Incomplete fracture is a partial separation of the bone : under 
which name are included Bending, Partial fractures, Fissures and 
Punctured or Perforating fractures, the last of which is almost pecu- 
liar to gunshot injuries. 

A Simple fracture is one in which the bone is broken at only one 
point. The term has no reference to the question of complications, 
but in its technical meaning, as employed by both English and Ameri- 
can surgeons, it has reference only to the number of fragments into 
which the bone is broken. It would be more correct, perhaps, to sub- 
stitute the word " single" for "simple,' ' as has been done by Malgaigne 
and some other French writers, but I fear that to American surgeons 
the substitution would be rather a source of confusion than otherwise. 

A Comminuted fracture, called by Malgaigne " multiple," is a frac- 
ture in which the bone is broken at more than one point, and in which, 
consequently, the bone is divided into more than two fragments. It 
is used also in a technical sense, and by no means implies minute divi- 
sion or comminution of the fragments. 

A Compound fracture is technically one in which there exists also 
an external wound communicating with the bone at the point of frac- 
ture. It may be either partial or complete, simple or comminuted, or 
even complicated, while at the same time it is also compound. 

Complicated fractures are such as present additional complications, 
or complications for which no other specific term has been invented. 
Thus the fracture may be complicated with the lesion of an important 
bloodvessel or nerve, or with great contusion or laceration of the soft 
parts, with a dislocation, or with fractures of other bones, or even with 
some constitutional fault. 

Fractures are also divided into Transverse, Oblique, and Longitu- 
dinal, according as the direction of the line of separation is at a right 



28 



GENERAL DIVISION OF FRACTURES. 



angle with the axis of the bone at the point of fracture, or as it deviates 
more or less from this direction. But a fracture is called transverse 
when it does not traverse the bone precisely at a right angle ; indeed, 
we usually apply this term whenever the obliquity is only moderate, 
not exceeding, perhaps, fifteen or twenty degrees, or when, in the 
examination of a limb,, although we are unable to detect the precise 
line of the fracture, we ascertain that, without being impacted or ser- 
rated, the ends of the bones continue to rest upon each other, or being 
replaced, do not spontaneously become displaced. 

Longitudinal fractures occur generally in connection with oblique 
or transverse fractures ; as when the lower end of the femur is split 
vertically into the joint, and the shaft of the bone is traversed hori- 
zontally by a fracture which intercepts the vertical or longitudinal 
fracture. A fracture of a condyle or of any projection from the 
body of the bone is called longitudinal if the direction of the line of 
fracture is parallel, or nearly so, to the axis of the shaft. 



Fig. 1. 



Fig. 2. 





Perforating and longitudinal fracture. 
From Surg. General's Circular. 



Impacted, extra-capsular fracture 
of neck of femur. 



A Serrated fracture is one in which the opposite surfaces denticulate, 
the elevations upon one fragment being reflected by corresponding 
depressions upon the other. 

Impacted fractures are those in which the fragments are driven into 
each other, the lamellated structure of one fragment penetrating the 
cancellous structure of the other. 

Writers also occasionally speak of fractures en rave, en bee de flute, 
en bee de plume, spiroid, cuneate, &c; but we do not see the propriety 
of multiplying the divisions and encumbering our nomenclature by 
these fancied resemblances. For all useful purposes, the divisions 
above given are sufficient. 

Epiphyseal separations we shall not hesitate to class, with fractures, 
and to submit them to the same rules of nomenclature. 



GENERAL ETIOLOGY OF FRACTURES. 29 



CHAPTEE II. 

GENERAL ETIOLOGY OF FRACTURES. 

The causes of fracture may be considered as predisposing and 
exciting. 

Predisposing Causes. — Partial fractures, with bending of the bones, 
are most frequent in infancy and childhood ; but complete fractures 
occur most often during manhood ; and if they are again less frequent 
in old age, it is because the exciting causes are less operative, since 
the fragility of the bones, as a general rule, increases with the age. 
It will be noticed, also, that somewhat in proportion as the bone is 
more brittle, its fracture will be more nearly transverse, so that very 
old persons have frequently what has been not inaptly termed the 
"pipe-stem fracture;" but we must except from this rule fractures 
occurring in children, which are also not unfrequently transverse, 
often denticulated or splintered, and but rarely oblique. In all of the 
intermediate periods of life, oblique fractures are by far the most 
common. Females are less liable to fractures than males, except in 
old age, when the law seems, in general, to be reversed. As to the 
season of the year, it has been generally observed by surgical writers, 
that fractures were more frequent in winter than in summer, and an 
explanation has been sought for in the greater rigidity of the muscles 
during the cold weather, and the greater liability to falls upon the ice 
and frozen ground. Some have affirmed that the bones themselves 
were more brittle; but aside from the improbability of this last 
explanation, it is a matter of question whether fractures are actually, 
more frequent in the winter than in the summer. If, on the one 
hand, the rigidity of the muscles and falls upon slippery walks are 
active causes in the production of fractures in the one season, on the 
other hand, falls from buildings and accidents from a great variety of 
similar causes, are equally active agents in the other. 

Mollities ossium, fragilitas ossium, rickets, cancer, tertiary lues, 
scrofula, gout, scurvy, mercurialization, and, in short, all diseases 
dependent upon cachexias, more or less predispose to the occurrence 
of fractures. Inflammation of the periosteum, also, or of the bone 
itself, may predispose to fracture. It is said, moreover, that the bones 
of persons who have lain a long time in bed break easily. 

Exciting Causes. — The exciting, determining, or immediate causes of 
fractures are of two kinds : mechanical violence and muscular action. 

Of these two, mechanical or external violence is much the most 
frequent cause*; and this violence may operate in two ways : by acting 
directly upon the bone at the point at which it separates, and then we 
say the fracture is "direct," or from "direct violence;" or by acting 
upon some point remote from the seat of fracture, and then we say the 



30 GENERAL ETIOLOGY OF FRACTURES. 

fracture is "indirect/' or from a "counter stroke." When a person 
falls from a height, alighting upon his feet, and the leg or thigh is 
broken, the fracture is indirect ; so also if the bone is broken by flexion 
or torsion. Even direct pressure upon one side of a long bone in a 
child may produce a partial fracture upon the opposite side, which is 
properly an indirect fracture ; or a direct blow upon the trochanter 
major may occasion a counter fracture through the neck of the femur. 

Fractures from muscular action occur most often in the patella, 
calcaneum, humerus, femur, tibia, and olecranon process of the ulna. 
These accidents imply generally some conditions of the bones them- 
selves which predispose them to fracture ; but I have seen one example 
of a fracture of the shaft of the femur in a large and perfectly healthy 
man, occasioned by a twist of the leg in rolling tenpins. I have also 
known the tibia and patella to break from natural muscular action in 
persons of uncommon vigor. Fractures sometimes occur in the violent 
contractions of the muscles during convulsions, and where no abnormal 
condition of the bones could be assumed to exist. Parker, of New 
York, relates a case of fracture of the humerus in a negro preacher, 
which occurred in the act of gesticulation ; also, a fracture of the 
clavicle occasioned by striking a dog with a whip ; in another case 
the humerus was broken in attempting to throw a peach ; but the most 
singular case of all was a fracture of the humerus caused by an effort 
to extract a tooth. 1 

Lente, of Cold Springs, New York, has seen both femurs broken in 
epileptic convulsions, in a child twelve years of age. The left femur 
was broken April 10th, 1859, at the junction of the upper with the 
middle third, and the right femur was broken at the same point eight 
months after, and about six weeks later he died. The first fracture 
united with considerable bowing and shortening. The second did 
not unite at all. He had been subject to epilepsy since he was fifteen 
months old. 2 

Eemarkable examples of fragility of the bones have been from time 
to time recorded. Gibson relates the case of a young man who at 
the age of nineteen had suffered twenty-four fractures. Arnott speaks 
of a girl who at the age of fourteen had suffered thirty-one fractures ; 
and Esquirol had in his possession the skeleton of a woman in which 
were found traces of more than two hundred fractures. In most of 
these cases, so far as is known, union occurred rapidly. 3 

Nearly all of the cases of fractures occasioned by muscular contrac- 
tion seen by me were transverse, or nearly so, indicating, perhaps, 
also, the existence of some unusual fragility ; and most of these have 
been unattended with shortening, the ends of the bones not becoming 
completely displaced from each other. The example of fracture of 
the shaft of the femur just mentioned, as having been broken in rolling 
tenpins, was, however, an exception. The bone shortened to the ex- 
tent of an inch or more, in consequence of overlapping, and in this 
position it has finally united. 

1 Parker, New York Journ. Med., July, 1852, p. 95. 

2 Amer. Med. Times and Advertiser, July 21, 1860, p. 41. 
8 Holmes' System of Surgery, vol. i. p. 745. 



GENERAL ETIOLOGY OF FRACTURES. 31 

Intra-uterine fractures are not yet fully explained, but it is probable 
that they, like extra-uterine fractures, may be ascribed sometimes to 
external violence, and at other times to simple muscular contraction, 
both perhaps acting upon bones already somewhat predisposed by a 
peculiar constitutional cachexy. 

Lawrence Proudfoot, of New York, has related a case of compound 
fracture in utero occurring in the practice of Dr. Freeman, which was 
apparently caused by external violence. Mrs. F., ast. 38, always 
having enjoyed good health, during the sixth month of gestation, 
while attempting to pass through a very narrow passage, was severely 
pressed upon the abdomen, and immediately experienced a severe pain 
in that region, accompanied with nausea and faintness. The following 
day, uterine hemorrhage with pain, commenced ; and these symptoms 
continued at intervals, in a form more or less severe, up to the period 
of her delivery, which occurred at full time, and was perfectly natural. 
At birth, the right foot of the child, a female, was found to be much 
distorted, and in a condition of valgus with equinus, the outer side of 
the foot being laid against the side of the leg above the external mal- 
leolus. The tibia, also, of the same limb, near its middle, seemed to 
have been the seat of a compound fracture ; the two ends of the bone 
having united at an angle slightly salient anteriorly, and the skin 
presenting over the point of fracture an old cicatrix. The soft tissues 
adjacent were considerably thickened. Seventeen months after birth, 
when the child was seen by Drs. Proudfoot, Van Buren, and Isaacs, of 
New York, the foot, although much improved by the means employed 
by Dr. Freeman, was still considerably deformed in consequence of 
the contraction of the tendo-Achillis ; on cutting which, the limb was 
found to be of the same length with the other. 1 

Dr. Aristide Eodrigue, of Hollidaysburg, Pa., has communicated a 
case of fracture with dislocation, which he ascribes to a similar cause. 
The woman, when about four months with child, fell on her left side, 
striking upon a board, and hurting herself severely. At the full period 
she was delivered of a well-grown male child. Its left humerus was 
found to be dislocated into the axilla, and both the radius and ulna of 
the same limb had been broken through their lower thirds, but were 
now united by bony callus at an angle of about 45°, and slightly 
overlapped. In all other respects the child was perfect. It does not 
appear that anything was done to the fracture, and the attempt to 
reduce the humerus was unsuccessful. Four years later Dr. K. saw 
the lad and found him strong and hearty, the dislocated humerus 
having grown nearly at the same rate with the opposite, but the 
forearm remained " short and deformed as at birth." The hand was 
of the same size as the hand of the sound limb. 2 

Devergie has given an account of a woman, who, when seven 
months with child, struck her abdomen against the corner of a table. 
Intense pain followed, lasting some time. She went her full period, 
however, and the child was then found to have a fracture of the left 

1 Proudfoot, New York Journ. Med., Sept. 1846, p. 199. 

2 Rodrigue, Amer. Journ. Med. Sci., Jan. 1854, p. 272. 



32 GENERAL ETIOLOGY OF FRACTURES. 

clavicle, the fragments being overlapped somewhat, and united in 
this position by a firm and large callus. 1 A woman also six months 
gone met with a similar accident, and at the full time she gave birth 
to a feeble child, having in one leg a separation of the shaft of the 
tibia from its lower epiphysis. The end of the shaft was necrosed 
and projected through a wound in the integument. This child died 
on the thirteenth day. 2 

Schubert reports the case of a female delivered before her term, of 
twins, one of whom was born with a fracture of the left thigh, which 
had occurred in utero ; the fractured bone had pierced the flesh, 
through which it projected more than an inch, and it was carious. 
The mother stated that about six weeks before the accouchement, 
during a movement of the foetus, she had heard a noise like that 
produced by breaking a stick, and from that moment she had felt 
pricking pains in her belly. 3 It is probable that in this instance the 
fracture was the result of a muscular action, although it is possible 
that it was occasioned by the thigh having become entangled between 
the legs of the twin. Similar cases have been recorded by Ploucquet, 
Kopp, Devergie, Carus, Schubert, Sachse, Moffat, and Brodhurst. 4 

In many other examples upon record 5 the explanation is plainly 
enough to be sought for in the abnormal or rachitic condition of the 
bones. Monteggia saw, in a newly born infant, twelve ununited frac- 
tures. Chaussier, who has published a memoir upon this subject, 
mentions two very extraordinary cases, in one of which the child pre- 
sented forty-three fractures, and in the other, one hundred and twelve. 6 
I myself was permitted to see, on the 29th of June, 1853, with Drs. 
Hawley and White, of Buffalo, an infant only four days old, who was 
born at the full time, of a healthy mother, in whom nearly all of the 
long bones were separated and movable at their epiphyses, the motion 
being generally accompanied with a distinct crepitus. The bones 
were also much enlarged in their circumference; the bones of the 
forearm and the femur were greatly curved ; the fontanelles unusually 
open, and the clavicles were entirely wanting. The child was of full 
size, but looked feeble. It died in a condition of marasmus six months 
after birth ; at which time some degree of union had taken place at 
several of the points of separation, the limbs having been supported 
constantly with pasteboard splints and rollers. 

I have also seen one example of complete separation of the tibia 
and fibula near the middle of the leg, which I was disposed to regard 
as defective development rather than as an instance of intra-uterine 
fracture: and a gentleman in Michigan has sent me an account of 
another, which I am inclined to think belongs to the same class of 
deformities, although he thought it might be a case of intra-uterine 
fracture. 

' Devergie, Rev. Med., 1825. 

2 Malgaigne, from Archive Gen. de Med., t. xvi. p. 288. 

3 Amer. Jonrn. Med. Sci., May, 1828, p. 223; from Zeitsch. fur Staatsarz von Henke, 
7e. Erg. Heft., p. 311. Holmes' Surgery, vol. iv. p. 826. 

4 Holmes' Surgery, vol. iv. 827, from Med.-Chir. Trans., vol. xliii., I860, art. 8. 

5 Lond. Med. Times and Gaz., April 7, I860. New Orleans Med. Journ., Nov. 1860. 

6 Chaussier, Bullet, de la Faculte de Med. de Faiis, 1813, p. 301. 



GENERAL SEMEIOLOGY AND DIAGNOSIS. 33 

Fractures occurring from violence inflicted upon the child by the 
accoucheur, or from contractions of the neck of the womb while the 
child is in transitu, are more common occurrences, and do not require 
a separate consideration. I shall mention several in connection with 
the various bones in which they have taken place; among which, one 
of the most interesting is that published by Dr. Jacob H. Vanderveer, 
of Long Branch, N". J. The mother came to bed on the 18th of 
January, 1847, after a labor of more than twelve hours. It was a foot 
presentation; the child weighed fourteen pounds, and was perfectly 
healthy, but one of the thighs had suffered a complete fracture, occa- 
sioned probably by the strong contractions of the cervix uteri. With 
careful splinting and bandaging, the bone was finally, but not without 
some difficulty, kept in position and made to unite, so that at the date 
of the report one would not discover that the bone had been broken, 
except by close inspection. 1 



CHAPTEE III. 

GENEEAL SEMEIOLOGY AND DIAGNOSIS. 

Fractures are liable to be confounded with contusions, and with 
various other local injuries, but most often with dislocations ; and 
especially when the fracture has taken place near one of the articu- 
lations, is the differential diagnosis sometimes rendered exceedingly 
difficult. It is with particular reference, therefore, to the general 
points of distinction between fractures and dislocations, that I now 
propose to speak. The special signs or points of difference which, 
belong to each individual case, will be considered in their proper 
places. 

The most important general, or common signs of a fracture — and by 
"common" signs I mean those which are common to most fractures — 
are crepitus, mobility, and an inability on the part of the fragments 
to maintain their positions when reduced ; indeed, in many cases, this 
constantly recurring displacement is due to the fact that the surgeon 
is unable to accomplish a complete reduction. While, on the other 
hand, dislocations are almost as uniformly characterized by the absence 
of crepitus, by preternatural immobility, and by the fact that when 
reduced the bones do not usually require support to retain them in 
place, or indeed, we may say, by the fact that they are generally 
reducible. 

Let us study these phenomena a little more in detail. 

Crepitus, occasioned by the chafing of the broken surfaces upon 
each other, when actually present, is almost positive evidence of the 
existence of a fracture. It is possible, however, to confound the chaf- 

1 Vanderveer, Amer. Journ. Med. Sci., May, 1847, p. 378. 



34 GENERAL SEMEIOLOGY AND DIAGNOSIS. 

ing of engorged tendinous sheaths, or of inflamed joints upon which 
fibrinous effusions have occurred, or of emphysema even, for the true 
crepitus of a fracture; but to the experienced ear and well practised 
touch these sensations are seldom a source of error. The one is rough, 
crackling, or even clicking sometimes, while the other is more sub- 
dued, and imparts a more uniform sensation to the hand, and but 
rarely conveys an actual sound, unless the ear is directly applied or 
the stethoscope is employed. It is only when the crepitus is trans- 
mitted obscurely through a great mass of soft tissues, or sufficient 
time has elapsed for the ends of the fragments to become softened by 
inflammation, and partially covered with a plastic material, or when 
indeed a dislocation is actually coincident with the fracture, that the 
surgeon is left in doubt. Occasionally, also, the existence of caries or 
of necrosis, in connection with a dislocation, might lead to the sup- 
position of a fracture; but the history of the case, aside from the 
remaining common signs, and the special symptoms hereafter to be 
enumerated, would prevent any possibility of error. In a few cases 
the diagnosis may be facilitated by the application of the ear or of the 
stethoscope, as first recommended by Lisfranc. 1 

It must not be forgotten, moreover, that a fracture at one point 
may transmit the sensation of crepitus distinctly enough, but in such 
a direction, owing to the relations of other bones to the one broken, 
as to mislead the surgeon, and induce him to locate the fracture in the 
wrong bone. Several examples of this species of deception I shall 
hereafter have occasion to mention. 

Valuable and important as is crepitus in its relations to differential 
diagnosis, unfortunately it is not always present, and for reasons 
which must be plainly stated. First; we cannot, in a pretty large 
proportion of cases, bring the broken ends again into apposition. 
Whatever mere theorists may say to the contrary, and notwithstand- 
ing surgeons up to this time have rarely ventured to allude to this 
subject, the fact is so that we do not usually " set" broken bones. "We 
do not, even at the first, bring them into complete apposition, unless it 
is as the exception. I speak of bones once completely displaced by 
overlapping, and these constitute the majority of examples which 
come under the surgeon's observation. Second ; in transverse frac- 
tures of the patella, and in fractures of the olecranon and coronoid 
process of the ulna, of the coracoid and acromion process of the 
scapula, and in all similar detachments of processes and apophyses, 
the action of the muscles, by displacing the fragments, prevents crepitus 
from being readily produced. Third ; in a few cases, such as certain 
fractures of the neck of the femur, of the neck and head of the humerus, 
&c, the broken ends are impacted, or so driven into each other as to 
forbid the production of motion and crepitus ; or they may be simply 
denticulated, and the consequences, so far as crepitus is concerned, 
will be the same. 

Finally, in very many incomplete fractures, crepitus does not exist, 
and even when it is present the sensation is feeble, or very much 

1 New England Med. Journ., 1824, p. 220. 



GENERAL SEMEIOLOGY AND DIAGNOSIS. 35 

modified, sometimes resembling the chafing of lymph, and at other 
times giving only a faint and single click. Under the head of crepitus 
we may properly include the sharp crack sometimes felt, or even 
heard by the patient at the moment of fracture. 

Preternatural mobility, less valuable as a means of diagnosis than 
crepitus, is nevertheless more constantly present, being never absent, 
in some degree, in all complete, non-impacted, and non-denticulated 
fractures ; but its presence does not, like crepitus, render the existence 
of a fracture quite certain. Whenever the bony lesion takes place in 
the vicinity of a joint, it may be difficult or impossible to determine 
whether the mobility of the limb is due to motion in the joint or to 
motion at the supposed seat of fracture. While on the other hand, 
the preternatural immobility so generally observed in dislocations, 
may give place to preternatural mobility, as when the ligaments and 
tendons surrounding the joint are extensively torn, or the system itself 
is laboring under the shock of the accident, or when from any other 
cause there exists great general prostration. 

As to the third common sign mentioned, namely, that in the case 
of fractures the bones do not generally support themselves, but de- 
mand for this purpose the interposition of splints, bandages, and even 
of extending and counter-extending forces, its authority rests upon 
the same evidence as does the assertion already made that bones once 
separated entirely, cannot generally be "set," that is, placed again end 
to end in such a manner as to be made effectually to support each 
other. It rests upon the evidence of my own personal experience ; to 
which I am permitted to add, also, the personal experience of Mal- 
gaigne, who, with a frankness which does him great credit, and which, 
I am sorry to say, has hitherto found few imitators, remarks: "Second. 
That overlapping is the most stubborn of all. Here I will add a dis- 
agreeable truth, which classical authors have kept too much out of 
sight, namely, that it is so stubborn that in an immense majority of 
cases the efforts of art are unable to overcome it." 1 And it must be 
observed further, that if we shall often find it possible to bring the 
broken surfaces sufficiently into contact to develop crepitus, they may 
still be unable to maintain themselves in this position, owing to the 
obliquity of the line of fracture. 

The other common signs of fracture may be briefly stated. Pain 
at the seat of fracture ; swelling ; ecchymosis ; deformity, produced 
by either an angular, transverse, or rotatory displacement of the frag- 
ments, and which is quite as often due to the direction and force of 
the impulse which occasioned the fracture as to the action of the mus- 
cles ; separation of the fragments, as in fractures of the patella and 
olecranon process ; and inability to move the limb, a phenomenon due 
in part to the breaking of the bony lever upon which the muscles 
acted, and in part to the intense pain caused by any such attempts. 
This latter symptom is, however, often entirely absent. It is not 
generally present in impacted fractures, in serrated and partial frac- 

1 Malgaigne, Traite des Fractures et des Luxations, Paris ed., t. i. p. 102. 



36 GENERAL SEMEIOLOGY AND DIAGNOSIS. 

tures, or in many other fractures in which the periosteum has not yet 
completely given way. 

Velpeau was the first, I think, to call attention to the fact that 
patients with broken clavicles could very generally raise the arm 
above the shoulder and even to the head, and I have repeatedly veri- 
fied the observation, notwithstanding the separation of the fragments 
has been complete, and the overlapping considerable. In fractures of 
the neck of the femur and of the tibia it is no uncommon thing for the 
patient to walk some distance after the receipt of the injury. 

I cannot dismiss this subject without calling attention to the neces- 
sity of exercising care and gentleness as well as skill in the examina- 
tion of broken limbs. Nothing, in my opinion, betrays a lack of 
judgment as well as of common humanity on the part of the surgeon, 
so much as a rude and reckless handling of a limb already pricked 
and goaded into spasms by the sharp points of a broken bone. It is 
not enough to say that such rough manipulation is generally unneces- 
sary, it is positively mischievous, provoking the muscles to more 
violent contractions, increasing the displacement which already exists, 
and sometimes producing a complete separation of the impacted, den- 
ticulated, transverse, or partial fractures, which can never afterwards 
be wholly remedied; augmenting the pain and inflammation, and not 
unfrequently, I have no doubt, determining the occurrence of suppu- 
ration, gangrene, and death. 

In proceeding to establish the diagnosis in any case, the surgeon 
should sit down quietly and patiently by the sufferer, so as to inspire 
in him from the first a confidence that he is not to be hurt, at least 
unnecessarily. He ought then to inquire of him minutely as to all 
the circumstances immediately relating to the accident, in order that 
he may determine as nearly as possible its cause, which alone, to the 
experienced surgeon, often affords presumptive, if not conclusive evi- 
dence as to the nature and precise point of the injury. From this, he 
should proceed to examine the disabled limb ; removing the clothes 
with the utmost care by cutting them away rather than by pulling ; 
and, when completely exposed, he should notice with his eye its posi- 
tion, its contour, the points of abrasion, discoloration, or of swelling ; 
and not until he has exhausted all these sources of information, ought 
the surgeon to resort to the harsher means of touch and manipulation. 
Nor will his sensations guide him to the point of fracture by any other 
method so accurately as when, the patient being composed and his 
muscles at rest, he moves his fingers lightly along the surface of the 
limb, pressing here and there a little more firmly, according as a trifling 
Indentation or elevation may lead him to suspect this or that to be the 
point of fracture. If the skin is more than usually tender, a few drops 
of sweet oil or of fresh lard laid upon its surface, or even moistening 
the skin with tepid water, will render this examination less painful, 
whilst it will facilitate the diagnosis, by rendering the tactile sensation 
somewhat more acute. 

The limb, in case of a supposed fracture of a long bone, may now 
be measured with a tape line, and compared with the opposite limb, 



REPAIR OF BROKEN BONES. 37 

having first marked with a soft pencil or with ink the several points 
from which the measurements are to be made. 

Finally, if any doubt remains, the limb must be firmly but steadily 
held while the necessary manipulations are performed, for the purpose 
of ascertaining the existence of mobility and of crepitus. Mobility is 
most easily determined by giving to the limb a lateral motion, but in 
general, crepitus is most effectually developed by gentle rotation. If 
the place of fracture is already pretty well declared by the previous 
examinations, the surgeon should place one finger over the suspected 
point, during this manipulation, by which means the crepitus will be 
more certainly recognized. 

I do not often find it necessary to resort to anaesthetics for the pur- 
pose of insuring quietude and annihilating pain in making these 
examinations, since it is seldom that the patient need to be much dis- 
turbed ; but if the examination is not satisfactory, and the diagnosis 
is important, I do not hesitate to render the patient completely insen- 
sible, after which the questions in doubt may be more thoroughly 
investigated and perhaps definitely settled. 

The surgeon ought not to forget, however, that while the patient is 
under the influence of an anaesthetic violent manipulations are no less 
liable to rupture bloodvessels, and to lacerate other tissues, than if 
employed when the patient is conscious. Surgeons have not seemed 
always to understand this, and the result has been that in too many 
instances they have inflicted serious and irreparable injury; in one 
instance tetanus and death has been the consequence. 

It is scarcely necessary to say that the earlier the examination is 
entered upon, the more readily will the diagnosis be made out ; and 
if, unfortunately, some time has already elapsed before the patient is 
seen by the surgeon, and much swelling has taken place, the exami- 
nation is still not to be omitted, and whatever doubts remain we must 
endeavor to remove by repeated examinations made from day to day 
until the subsidence of the tumefaction has brought the surfaces of the 
bone again within the reach of our observation. 



CHAPTEE IV. 

EEPAIR OF BROKEN BONES. 

It is not my intention to enter very fully into a consideration of the 
process of repair in fractures, preferring to leave this subject where it 
more properly belongs, to the general treatises on surgical pathology. 
And especially am I disinclined to this topic, because of the discrep- 
ancy of opinion which has all along existed upon many of the points 
involved, and which differences still continue to exist, even among 
the best informed pathologists, and to the final settlement of which I 



38 EEPAIE OF BROKEN BONES. 

confess I have ntft brought, except perhaps in relation to one single 
point, any new observations or labors. 

I only propose to state very briefly a few practical, and I trust I 
may now say, pretty well established facts, such as the manner or 
position in which this reparative material, whenever it is employed, 
is applied to the broken bones, the length of time which is usually 
required for the completion of the process of repair, and the causes 
which may impede or prevent bony union. 

If I think it necessary to say anything more upon this subject, it 
will be simply to announce my belief that the reparative material, 
consisting originally of a plastic lymph, is poured out from the vessels 
of the medullary membrane, the periosteum, the broken ends of the 
bone, and more or less from all of the lacerated tissues which are 
immediately adjacent to the seat of fracture ; that after a period, longer 
or shorter, this lymph becomes organized, and begins to receive from 
the same sources particles of bony matter, through which the con- 
solidation is finally effected ; that the transition from the original 
plastic material to bone is almost constantly through the interposition 
of a fibrous tissue, rarely, unless in the case of children, through a 
cartilaginous tissue, and sometimes through both consentaneously or 
consecutively ; that, perhaps, in a few fortunate examples bones unite 
directly or immediately, without the intervention of a reparative 
material : and finally, that granulations, or inflammatory exudations 
become transformed into bone, or perhaps we are only authorized to 
say that they immediately precede ossification, in certain cases of 
compound fractures, or of fractures in which the process of inflamma- 
tion exceeds certain limits. 

This last proposition, in reference to the agency of granulations in 
the production of callus, or their mutual pathological relations, is at 
the present more in debate than either of the others ; but, with this 
exception, it will be seen that I have carefully avoided all of those 
points upon which the observations and opinions of pathologists are 
still greatly at variance. 

Dupuytren, enlarging upon the doctrines taught by Galen, Duhamel, 
Camper, and Haller, declared that "nature never accomplishes the 
immediate union of a fracture save by the formation of two successive 
deposits of callus ;" one of which is derived from the periosteum and 
from the adjacent tissues, and from the medulla ; while the other, de- 
rived, perhaps, from the broken extremities of the bone itself, is found 
at a later period directly interposed between these surfaces. The 
material or callus derived from the tissues outside of the bone, and 
which Gralen compared to a ferule, but which Mr. Paget calls "en- 
sheathing," together with the material derived from the medulla, com- 
pared often to a plug, and by Mr. Paget named "interior" callus, are 
by Dupuytren spoken of as the " provisional," or temporary callus, 
by which the fragments are supported, and maintained in contact 
until the permanent callus is formed. This temporary splint is com- 
pleted, or has arrived at the condition of bone in a spongy form at 
periods varying from twenty to sixty days ; but it does not assume 
the character of compact bone until a period varying from fifty days 



EEPAIK OF BEOKEN BONES. 39 

to six months, has elapsed ; after which it is gradually removed by 
absorption. The second process, by which the ends of the bone are 
definitively or permanently united, commences when the provisional 
callus has arrived at the stage of spongy bones, and is not completed 
usually within less than eight, ten, or twelve months, " when," says 
Dupuytren, " it acquires a solidity greater than the original bone." 

While it is certain that this eminent surgeon aud most accurate 
observer has described faithfully the various phenomena which usually 
accompany the repair of bones in those animals which were the 
subjects of his experiments, and that his conclusions have a certain 
degree of application to the human species, it is equally certain that 
he erred in assuming that in man simple fractures always unite by 
this double process ; yet, such is the power of authority, these doctrines 
were accepted from the first without hesitation or debate, and for 
nearly half a century they have occupied the minds of surgeons to 
the almost complete exclusion of every other theory. Mr. Stanley 
was among the first to question the solidity of the doctrines of Dupuy- 
tren, but it remained for Mr. Paget to fully expose their many falla- 
cies; nor has Malgaigne, although not strictly a disciple of Paget, 
failed to detect certain of these errors. 

I should also do injustice to myself were I not to mention that at 
the very moment when Mr. Paget was making his observations upon 
the specimens in "the large collection of fractures in the museum of 
the University College," I was myself employed in similar researches 
both among cabinet specimens and in the hospitals of this country and 
of Europe; and that the conclusions to which I had arrived were 
nearly identical with, although the inferences were far from being so 
complete in their detail, as those to which this distinguished patholo- 
gist was himself brought. 1 I do not, however, wish to make Mr. Paget 
responsible for any of the opinions upon this subject which I shall 
hereafter express, except so far as they may be found to agree with 
his own published views. 2 

I think it may now be fairly stated that the repair of bones by the 
double process described by Dupuytren, is, in man, only an exception 
to a very general rule ; and that fractures may unite by either one of 
the following modes : — 

First. Immediately, or in the same manner that the soft tissues 
sometimes unite, by the direct reunion of the broken surfaces, and 
without the interposition of any reparative material. This happens 
probably sometimes in the spongy bones, and in the extremities or 
spongy portions of the long bones, especially when one portion of bone 
is driven into another and becomes impacted ; as in certain fractures 
of the neck of the humerus or of the femur. 

Second. By interposition of a reparative material between the broken 
ends ; as when the fragments remain in exact apposition, but immedi- 
ate union fails. This is especially apt to occur in superficial bones, 

1 Paper on " Provisional Callus," by Frank H. Hamilton. Buffalo Medical Journal, 
Feb. 1853. 

2 Lectures on Surgical Pathology, by James Paget, Phila. ed., 1854, Chapter XI. 



40 REPAIR OF BROKEN BOXES. 

such as the tibia; or -upon those sides of the bone which are most 
superficial. It is not an unusual circumstance to find the shaft of the 
tibia during the process of union presenting no exterior callus upon 
its anterior and inner surface, whilst the posterior and outer section of 
its circumference is covered with an abundant deposit. In other cases, 
however, of fractures of the shaft as well as of the epiphyses, the 
intermediate callus secures a prompt union, bat no ensheathing callus 
is ever formed. 

Third. Bones broken and not separated, unite occasionally by the 
process described by Dupuytren, namely, by the formation, first, of an 
ensheathing callus, whilst at the same moment the cylindrical cavity 
becomes closed by a spongy plug or a compact septum of bone; and 
second, by definitive callus deposited between the broken ends. It is 
probable that this happens generally in children, and it is a common 
mode of union in the ribs, which bones, during the wbole progress of 
the union, are necessarily kept in motion. My cabinet furnishes many 
illustrations of ensheathing callus in ribs ; and also a few in fractures 
of the tibia and fibula. 

Fourth. Under similar circumstances, where no displacement exists, 
the fracture may unite by ensheathing and interior callus alone, no in- 
termediate callus ever being formed between the broken ends; in which 
case it may be properly said that the bone itself has never united, and 
the ensheathing callus instead of being provisional is permanent or 
definitive. This was essentially the doctrine of Galen, Haller, and 
Duhamel before Dupuytren added his " fifth period," or the formation 
of definitive callus ; and by these older surgeons it was held to be of 
universal application, except perhaps in the case of children. To this 
doctrine also Malgaigne has returned — at least to the question " Is 
there always a definitive callus, or complete union of the fragments?" 
he has made this laconic reply : " Galen admitted its occurrence, but 
only in young subjects; it has been obtained in animals, where there 
had been no displacement. I would willingly believe that such is 
sometimes the case in human adults; but I must confess I have seen 
only the instance above cited, which might just as well be used to 
prove the compact ossification of the provisional callus." He accepts, 
therefore, the doctrine of Galen as having not merely an occasional 
application, but as explaining the process of union in the large ma- 
jority of cases ; and in support of this extreme view he finds that the 
exterior callus, which Dupuytren called provisional or temporary, is 
actually permanent unless removed by the absorption consequent 
upon pressure. 

To all of which we can only say that an examination of five or six 
specimens in our own cabinet, after having carefully divided them 
with a saw, has furnished only one illustration of union by ensheathing 
and interior callus alone. In each of the other specimens the union 
was completed by definitive or intermediate callus. We cannot, 
therefore, avoid the conclusion that Malgaigne has been deceived as 
to the relative frequency of these different modes of union, and that 
union without intermediate callus is exceptional. ' - 

Fifth. When bones are broken and overlap, they may unite by the 



REPAIR OF BROKEN BONES. 



41 



interposition of a callus between the opposing surfaces, that is, by an 
intermediate callus, but which will differ from that described as the 
second method, inasmuch as the new material will be deposited upon 
the sides of the fragments and not upon their extremities. The limb 
being kept perfectly at rest, and all other circumstances proving 
favorable, this union may take place without any excess or irregularity 
in the deposit. The surfaces will unite firmly where they are in actual 
contact, aod smooth and well-formed buttresses will fill up all the 
spaces between the bones where they are not in actual contact, suffi- 
cient generally to give the requisite strength to this new bond of 



Fig. 3. 



Fig. 4. 




Fracture of the thigh of a turkey ; united with the frag- 
ments widely separated. From a specimen in the author's 
cabinet. 

union. This mode of union will be 
completed sometimes when the two 
ends of the bones are separated later- 
ally an inch or more from each other. 
I have in my collection the bone of a 
turkey's thigh (Fig. 3) thus united by 
a transverse bony shaft, although sepa- 
rated more than one inch ; and what is 
less common, I possess also a specimen 
of the adult human thigh (Fig. 4), in 
which an oblique shaft of solid callus 
has, after many months, and while no 
splints were employed, bound together 
firmly the two opposite extremities of 
the broken bone. 

Sixth. The fragments being overlap- 
ped more or less, and suffering unusual 
disturbance, or the adjacent tissues 
having been much torn, or much blood 
being effused so that considerable in- 
flammation is caused, the amount of cal- 
lus will exceed what is necessary for 
the complete union of the bones ; and this redundancy may be deposited 
around and upon the broken ends of the bones, or anywhere in their 
immediate vicinity, in layers, or in masses of irregular shape and size. 
Even the bones which are not broken, but which are near, as in the 
case of the fibula after a fracture of the tibia, may become inflamed, 
or their coverings may inflame, and they may also contribute to the 
general mass of bony callus. 
4 




Fracture of the shaft of the femur; united 
with an oblique callus. From a specimen 
in the author's cabinet. 



42 REPAIR OF BROKEN BONES. 

Compound fractures, or rather, we ought to say, fractures accom- 
panied with granulations and suppuration, obey no uniform law of 
repair, so far as the manner and position of the deposit are concerned; 
but they come together finally with more or less irregular distributions 
of ossified matter, according to the varying circumstances of imperfect 
coaptation, mobility, &c, in which they may chance to be placed. 
Occasionally the amount of callus is less than occurs in simple frac- 
tures, and at other times the excess is very great. 

In short, we conclude that fractures of adult human bones, whether 
placed end to end or overlapped, unite most naturally and most 
promptly either immediately or mediately, and in the same manner 
that soft tissues unite ; that is to say, without the interposition of any 
reparative material, or through the medium of an intermediate, 
permanent callus ; and that all deviations from these simple methods 
are accidential, or the result of disturbing influences. 

That was, no doubt, a beautiful thought, which ascribed the form- 
ation of provisional callus to an intelligent efficient cause, which in 
this manner sought to support the fragments until a reunion of their 
divided ends was accomplished. But the beauty of a conception 
supplies no evidence of its truth ; and we have grave doubts whether 
Nature ever allows any interference with her laws even in an exigency, 
unless by the substitution of a miracle. Provisional callus is, in our 
opinion, just as much the necessary result of natural laws, as is defini- 
tive. It is formed because in that condition of the parts and of the 
general life its formation was inevitable. Whether useful for the 
purposes of repair or not, it will, under certain circumstances, exist. 
In the repair of certain fractures, provisional callus, it is conceded, 
seldom occurs. Thus it is with the cranium, the acromion, coracoid 
and olecranon processes, the patella, and with all those portions of 
bones which are immediately invested with a synovial capsule. Will 
it be affirmed that in the examples just named this callus is not formed 
because it is not required? To us it seems that nowhere could it 
prove more useful, since, with the single exception of the cranium, it 
is in these very cases that the obstacles to a reunion are the most 
serious. In fractures of the patella, olecranon, &c, the action of the 
muscles tends constantly and powerfully to displace the fragments, and 
gladly would the surgeon avail himself of the assistance of a tem- 
porary callus, but it is rarely present, at least in any useful degree. So 
also in fractures of the neck of the femur within the capsule, and in 
other similar cases, we cannot say that temporary callus would not be 
advantageous in facilitating the retention of the fragments, yet the 
" intelligent efficient agent " neglects to furnish it. 

The only satisfactory reason which, as we think, can be assigned for 
the absence of callus in these cases, is found in the doctrines we now 
advocate ; that is to say, it is usually absent because that amount of 
excitement and irritation is usually absent which alone determines its 
formatiou. In the case of the olecranon, patella, &c, the fragments 
being separated from each other by muscular action, so that no painful 
pinchings or chafings occur, and their rough surfaces or sharp points 
being rather drawn away from, than protruded into the flesh, no 






EEPAIE OF BROKEN BONES. 43 

sufficient provocation exists for the production of inflammation and 
effusion. Hence the failure of provisional call us, but wherever the frac- 
ture occurs, and however moderate the action, definitive callus does 
not fail; still the broken surfaces of the patella and olecranon are 
softened, and smoothed, and covered over with a new matter, which, if 
contact could have been secured and preserved, would certainly have 
served to consolidate and repair the breach. The natural reparative 
process proceeds, but only the accidental process is omitted. This 
latter, however, is seen again even here, when from other and unusual 
causes a sur-excitement is established. 

Temporary callus is not formed upon bones invested with synovial 
membranes, because here, too, as in the neck of the femur, there are 
not so many structures lacerated and irritated, and the supply of this 
effusion must be the less not only in proportion to the less intensity 
of the inflammation, but also to the less amount of structures impli- 
cated. 

Possibly other and more satisfactory reasons may be assigned why 
provisional callus is not formed usually when the neck of the femur 
is broken within the capsule ; but we certainly can never admit the 
common, and, as here applied, the too palpably absurd explanation, 
that it is not wanted. It is wanted, and in no case so much as in the 
one now supposed. 

Provisional callus has, therefore, no final purpose, but it is the 
unavoidable result of certain abnormal conditions. It still occurs 
everywhere when against and in the vicinity of the bone there is the 
requisite lesion and action, and it will occur as certainly when there 
is no fracture at all, but only a caries, a necrosis, or a simple bony or 
periosteal inflammation ; and whilst it is doubtless true that in fractures 
it sometimes renders valuable aid to the surgeon, it is equally true 
that it often proves a source of hindrance. 

From these remarks I choose to except fractures occurring in chil- 
dren, in relation to which the observations are not yet sufficiently 
numerous to determine absolutely the laws of repair. If, however, I 
were to venture an opinion based upon a few examinations, I should 
say that in children we may accept with but little qualification the 
doctrine of Dupuytren as already explained. 

Dupuytren, in determining the limits of his " third" period, or of 
that in which a provisional callus is formed of sufficient strength to 
support the fragments, has given what has been usually quoted as the 
natural period within which bones may be said to be united, that is, 
" from the twentieth or twenty-fifth day, to the thirtieth, fortieth, or 
sixtieth." But this depends so much upon the age of the patient, his 
general condition of health, the condition and position of the broken 
ends, as well as upon the bone itself) and the point at which it is 
broken, with many other circumstances, that it would be unsafe to 
establish any absolute laws in reference to this point. 

In very early infancy, union is accomplished in half the time re- 
quired in adult life, and it is generally thought to be still more re- 
tarded in advanced age, but Malgaigne has not found this latter- 
observation confirmed by his own experience. Various constitutional 



44 GENERAL TREATMENT OF FRACTURES. 

causes, as we shall "hereafter explain more fully, retard bony union. 
Motion, also, sometimes delays consolidation : fragments which are 
overlapped do not unite as speedily as those which are placed end to 
end, and other complications interfere in a similar manner, such as 
lesions of nerves, of bloodvessels, comminution of the bone, the inter- 
position between the ends of the fragments of a blood-clot, a portion 
of muscular, tendinous, or other tissue, &c. It is affirmed, moreover, 
that in general the bones of the lower extremities, independently of 
their size, unite more slowly than the bones of the upper extremities. 

Epiphyses, when separated, unite by the same process as fractures of 
the bone. It is affirmed, however, that, when certain epiphyses unite 
with much displacement, the shafts from which they have been sepa- 
rated cease to grow, and the limb becomes atrophied. 

For a more complete consideration of the causes which retard the 
union of bones, I beg to refer the reader to the chapter on " Delayed 
Union, and Non-Union of Bones." 



CHAPTEE V. 

GENERAL TREATMENT OF FRACTURES. 

All that has been said in relation to the propriety of handling a 
broken limb gently when the surgeon is examining the position and 
character of the fracture, is equally applicable to the lifting and trans- 
porting of the patient to his bed, to the removal of the clothing, and 
to the general management of the limb before it is dressed. Rude or 
awkward manipulations, by which needless pain is inflicted, are not 
simply acts of wanton cruelty, but they are sources, and I think I may 
say frequent sources, of inflammation, suppuration, and gangrene. 
Here, as in all the subsequent handlings, everything should be done 
slowly, thoughtfully, and systematically. Yet it is difficult to state 
the precise manner in which the surgeon ought to proceed. Much 
will depend upon the circumstances of the case, something upon one's 
natural tact, and upon the amount of experience, but more, I think, 
upon natural kindness of heart, and social education. The man of 
refinement and sensibility will know instinctively how to proceed, 
and needs no instruction. They who lack these qualities can never 
learn, and it would be quite useless to undertake to teach them. I 
sincerely wish such men as these latter would find some more suitable 
employment than the practice of a humane art. 

Nearly all fractures present three principal indications of treatment, 
namely : to restore the fragments to place as completely as possible ; to 
maintain them in place ; and to prevent or to control inflammation, 
spasms, and other accidents. 

It ought to be regarded as a rule, liable only to rare exceptions, 
that broken bones should be restored to place, or to the position in 



GENERAL TREATMENT OF FRACTURES. 45 

which we hope to maintain them, as soon as possible after the occur- 
rence of the accident. If the patient is seen within the first few hours, 
or before much swelling has taken place, we scarcely know the cir- 
cumstance which would warrant an omission to adjust the fragments 
either end to end or side by side, as the one or the other might be 
found to be practicable. We have before sufficiently explained the 
general impossibility of again restoring to place, end to end, and fibre 
to fibre, fragments which have been made to override. We are there- 
fore in no danger of being understood to say that bones should in all 
cases be immediately " set," in the popular sense of this term. They 
ought to be " set," no doubt, if this can be accomplished through the 
application of a prudent amount of force ; but if they cannot be thus 
placed end to end, they may at least be laid in such a manner side by 
side as to restore, in some measure, the natural axis of the limb, and 
prevent the points of the bone from pressing unnecessarily into the 
flesh. 

Experience has indeed furnished us with four or five very good 
reasons why broken bones should be reduced as soon as possible. 
When the injury is recent, the muscles offer less resistance; their 
resistance being increased after a time not only by the reaction which 
ensues upon the shock, but also by actual adhesion between their 
fibres ; effusions distend both the muscles and the skin, and compel 
the limb to shorten ; the constant goading of the flesh by the sharp 
points of the broken bones increases the muscular contractions ; the 
patient will submit readily to manipulation and extension at first, but 
after the lapse of a few days, it is very seldom that he will permit the 
limb to be in any manner disturbed, even if he is assured that his 
refusal entails upon him a great deformity. If it is true that no callus 
or bony structure is deposited earlier than the seventh or tenth day, 
it is also true that the renewed attempt to adjust the bones at this 
period, by chafing and tearing again the tissues, reduces the fracture, 
in some degree, to the same condition in which it was at first, and, 
consequently, the time which has elapsed, or, at least, a portion of it, 
may be regarded as lost. 

We cannot, therefore, understand the argument by which Brom- 
field, South, and a few other surgeons have persuaded themselves 
that reduction should never be attempted before the third or fourth 
day; nor, indeed, do we fully appreciate the refinement which Mal- 
gaigne has given to this question in itself so simple. To affirm that 
we ought not to reduce the bones to their original positions during 
the period of intense inflammation, or of great swelling, or while the 
muscles are acting spasmodically, is only to affirm that we may not 
do what is impossible ; and the attempt to do which, therefore, can 
only be mischievous ; but to authorize their restoration to a better 
position, by such manipulation, extension, and lateral support as they 
may comfortably bear, is warrantable under any circumstances. The 
practice is not only defensible but imperative, and we do not think 
any really sound and practical surgeon ever intended to teach the 
contrary. We say still, if bones can be easily reduced, or the position 
of the fragments improved at any moment or under any circumstances, 



46 GEXEEAL TREATMENT OF FRACTURES. 

Fig. 5. Fig. 6. 






r?iT ^p^> l 


pi 


""/IfmpN 


ffiuu. 


,-r.illj 




_jW 








Many-tailed bandage. 



Application of the 
versed turns. 



: roller" by circular and re- 



it ought to be done ; and if we fail 
in accomplishing all that we wish 
to do in the first instance, we must 
remain incessantly watchful to 
seize the earliest opportunity 
which presents, to complete the 
adjustment. No doubt our efforts 
will prove fruitless very much in 
proportion to the amount of swell- 
ing, inflammation, or muscular 
spasm which exists, and also in 
proportion to the time which has 
elapsed, but this will not excuse 
us for omitting to do all which the 
circumstances permit. 
It has been the practice of most surgeons, for a long period, to cover 
the broken limb with some form of a bandage or roller before apply- 
ing the lateral splints. 

Of these primary dressings there are two principal varieties : first, 
the "roller," or simple bandage, applied to the limb in circular and 
reversed turns; and, second, the "many -tailed bandage," consisting of 
a piece of muslin, or other cloth, torn down from each side into a 
suitable number of strips, leaving the centre, which is to be applied 
to the back of the limb, entire. 

A modification of this latter bandage consists of a number of separate 
strips, so laid upon one another, commencing from above, as that each 
strip shall overlap the other by one-third or one-half of its breadth. 
This is called the bandage of Scultetus, and it possesses one advantage 
over the many-tailed bandage just described, especially in the case of 
compound fractures, in the facility with which each separate piece 
may be removed and another substituted. Some surgeons prefer to 
form the bandage of separate strips, and having overlaid them in the 
manner directed, to unite them again into one by running a thread 
through the whole mass along the centre. 

Whichever of these several varieties of strips are employed, the 
mode of applying them is the same. They are folded alternately 



GENERAL TREATMENT OF FRACTURES. 



47 



around the limb, being made to overlap and cross upon each other in 
front, and only the last strip or two is fastened with a pin. 



Fig. 7. 



Fig. 8. 





Application of the many-tailed bandage. 



Bandage of Scultetns. 



The object proposed in the use of the roller or of the many-tailed 
bandage is twofold : first, to compress and support the muscles, by 
which their tendency to contraction is in some measure controlled ; 
and second, to protect the limb against the direct pressure of the side 
splints. 

A moment's consideration will convince us that the first of these 
objects is in most cases fully attained by the lateral splints themselves, 
and by the bandages by which they are retained in place ; and that 
the second can be as well accomplished by a single fold of cloth, or by 
the compresses, which ought generally, even when the roller is used, 
to underlie the splints. Nevertheless we should hardly feel authorized 
to reject these primary dressings solely because the splints and com- 
presses furnish a convenient substitute, especially since we are com- 
pelled to admit that they are occasionally useful, unless objections of a 
more serious nature could be brought against them. Unfortunately 
this latter supposition is actually true. By ligating the limb com- 
pletely, leaving no point of the tegumentary surface to which the 
pressure is not applied, they too often occasion congestion, inflamma- 
tion, and gangrene. It is not until lately that the attention of surgeons 
has been sufficiently called to this subject ; but the records of surgery 
are to-day filled with these terrible accidents, formerly attributed to 



48 GENERAL TEEATMENT OF FRACTURES. 

the original injury or to the splints themselves, but now understood 
to be plainly traceable to the too common employment of the primary 
bandage. The roller is by far the most dangerous dressing of the two, 
since it does not yield to the swelling so readily as the bandage of 
strips, and it is more objectionable also on account of the inconve- 
nience of applying and removing it ; but even the bandage of strips 
may be so confined as to produce the same consequences, as I have 
myself seen in more than one instance. It is also all the more dan- 
gerous in the hands of the inexperienced surgeon, because he feels 
a confidence that it will not cause ligation. 

Except in rare cases and for especial reasons, which we shall attempt 
to indicate in their appropriate places, we cannot recommend the em- 
ployment of any kind of bandages next to the skin. 

In order to fulfil the second indication, namely, to maintain the 
fragments in place, we employ usually what are called short, side, or 
coaptation splints, and long or extending splints, or the weight and 
pulley. 

Side splints may be constructed from various materials, according to 
the size and circumstances of the limb, or according to the convenience 
of the surgeon ; and as the surgeon cannot be expected to have always 
on hand, at the bedside of the patient, such splints as he might prefer 
to use, it is well for him to understand how to avail himself of such 
materials as may be within his reach, in order that he may make the 
most of his sometimes imperfect resources. 

Lead, sheet iron, zinc, and other metals have been occasionally em- 
ployed, but especially tin and copper, which possess all of the requisite 
firmness and malleability to allow them to be hammered and thus 
moulded to the limb. In general, however, they are unnecessarily 
heavy, and demand too much labor to be wrought into shape. I have 
sometimes employed tin splints perforated with large fenestrse to 
diminish their weight and increase their flexibility, and found them 
to answer an excellent purpose. The light perforated zinc splints, 
introduced into the U. S. Army by the Sanitary Commission, through 
the agency of Dr. E. Harris, of New York, were found exceedingly 
useful. 

Iron wire splints, made from wire cloth or coarse gauze, were first 
publicly mentioned, so far as I can learn, in a communication to the 
Memphis Medical Recorder, made by Dr. J. C. Nott, of Mobile ; but they 
have been brought more particularly into notice, and their construction 
perfected by Louis Bauer, of New York. 1 These splints are moulded 
upon " gypsum or wooden casts," of different sizes, and surrounded with 
a stout iron wire frame in order to give them the requisite degree of 
firmness, and to preserve their forms ; after which they are tinned by 
galvanism, and varnished, to prevent them from becoming rusted. 
When applied, Dr. Bauer recommends that they shall be filled with 
loose cotton, and that they shall be held in place by rollers. It is 
claimed for these splints that they are light, flexible, permeable to air 
and to the perspiration, and that they permit the application of cool- 

1 Nott and Bauer, Buf. Med. Journ., vol. xii., April, 1857. 



GENERAL TREATMENT OF FRACTURES. 49 

in°- lotions without impairing their firmness ; the last of which is a 
quality of questionable value, since lotions applied to permanent 
dressings of any kind are only warm fomentations, and do not, there- 
fore, in this respect serve the purpose for which they were intended ; 
besides that they render the skin tender, and disposed to vesicate, 
they give rise to a sensation of scalding, which is sometimes almost 
intolerable ; they soak into the bed, and in many other ways render 
the patients uncomfortable. Cooling lotions are only applicable where 
the dressings are open, loose, and temporary. 

The same objections hold also to this as to all other forms of 
moulded metallic or carved wooden splint, namely, that they seldom 
exactly fit the limb, even when the supply of assorted sizes is com- 
plete, and that they are not sufficiently flexible to adapt themselves 
to anything but the slightest irregularity of surface. They are not, 
however, without merit, and they deserve at least a qualified recom- 
mendation in many cases. I shall refer to them again when speaking 
of fractures of the thigh and leg. 

Horn and whalebone ma}' be employed in thin plates, or in the form 
of narrow strips quilted into cloth ; but they are expensive and pos- 
sess no special value except in an emergency. Eeeds, the coarse rank 
grass which grows in swamps, flags, willow branches, and unbroken 
wheat straw, may be quilted between two thicknesses of cloth in the 
same manner, and form very excellent temporary splints. I have 
especially found it convenient to use wheat straw in the form of junks. 
Gathering up a bundle of unbroken straws of the size of my arm, I 
roll them snugly in a broad piece of cotton cloth, cut off the projecting 
ends, and then stitch up the cloth neatly. We have thus a splint of 
considerable firmness, and one which is cool and especially adapted 
to the summer, allowing the perspiration to evaporate freely. Straw 
splints were employed sometimes by Ambrose Pare, by J. L. Petit, 
Larrey, and I have several times seen them in the wards of certain 
European hospitals, although I am unable now to say under whose 
direction. Mr. Tufmell, of Dublin, has especially recommended them 
in the form of junks. 1 

Wooden splints, made of pine, willow, white or linden wood, or of 
some other light and easily wrought timber, are probably of more 
universal application, and possess greater intrinsic value than splints 
constructed from any other material ; but I wish at once, and for all, 
to disclaim any intention of giving even a qualified approval of any 
of those carved, polished, and generally patented wooden splints, which 
are manufactured and sold by clever mechanics, and which one may 
see suspended in almost every doctor's office, whether in the city or 
in the country. Constructed with grooves and ridges, and variously 
inclined planes, for the avowed purpose of meeting a multitude of 
indications, such as to protect a condyle, to press between parallel 
bones, to follow the subsidence of a muscular swelling, &c, they never 
meet exactly a single one of these indications, whilst they seldom fail 
to defeat some other indication of equal importance. They deceive 

1 Tuffnell, New York Journ. Med., March, 1847, p. 264. 



50 GENERAL TREATMENT OF FRACTURES. 

especially the inexperienced surgeon into the belief that he has in the 
splint itself a provision for all these wants, and consequently lead him 
to neglect those useful precautions which he would otherwise have 
adopted. 

If carved wooden splints are employed, they ought to be made 
especially for the case under treatment. But this requires time and 
some more mechanical skill than can always be commanded ; and when 
accurately fitted, it is quite probable that the subsidence or increase 
of the swelling will, within the next forty-eight hours, render some 
change in the form of the splint necessary, or compel the surgeon to 
throw it aside. 

We much prefer to use plain, straight strips of wood, of the requisite 
width and length, which may be cut at any moment from a shingle or 
a thin piece of board. 

In order that these splints may adapt themselves to the inequalities 
of the limb, and properly support the fragments, they may be under- 
laid with pads or junks of a suitable thickness ; or, what is still better, 
they may be covered with a muslin sack, open at both ends, into 
which, and on the side of the splint which is to be placed against the 
limb, bran, wool, cotton batting, or curled hair may be pressed, until 
it is made to fit accurately. I generally prefer cotton batting. Bran 
is liable to get displaced, and curled hair does not pack firmly enough. 
"When the sack is sufficiently filled, the two ends must be stitched up. 
This mode of constructing the splint is simple and easy of accomplish- 
ment ; the splint can be fitted very accurately ; the pad never becomes 
displaced ; and when the bandages are applied, they may be pinned or 
sewed to the cover in such a way that they shall not slide or loosen. 

If pads are employed separate from the splint — and for this purpose, 
also, I generally prefer the cotton batting — they ought to be made and 
fitted with the same care, and neatly stitched together at their ends, 
rather than pinned. Cotton batting laid loosely next to the skin, or 
underneath the splints at any point, will not keep its place so well as 
when it is inclosed in covers — it is more liable to get into knots, and 
it has altogether a slovenly appearance. The pads may be stitched 
to the roller, and in this way secured effectually in place, but loose 
cotton is subject to no control. 

When I speak of pads, it must not be understood that I intend to 
recommend them for compresses, or for the purpose of pressing frag- 
ments into place. Nothing could be a greater source of mischief in 
the dressing of a broken limb. I have only directed their employ- 
ment as a means of adaptation, and to protect the skin against the 
direct pressure of the splint. 

Dr. Jacobs, of Dublin, says that he has seen an excellent splint made 
from the " fresh bark of a tree taken off while the sap is rising." " It 
fits admirably," says Dr. Jacobs, "just like pasteboard soaked in water." 1 
Dr. C. C. Jewett, of the 20th Mass. Vols., recommends for the same 
purpose the bark of the liriodendron, or tulip tree. 

Undressed sole-leather, cut into shape and soaked a few minutes in 

1 Jacobs, Xew York Journ. Med., March, 1S47, p. 265, from Dublin Med. Press. 



GENERAL TREATMENT OF FRACTURES, 



51 




Wood and leather splint. 



water, adapts itself easily to the limb and is sufficiently firm. It is 
especially applicable to fractures of the larger limbs. At Bellevue 
Hospital it has of late taken the place of almost all other materials. 

A splint is also occasionally made of thin calf skin veneered with 
some light timber, such as linden or white wood, the latter being sub- 
sequently split into strips of from half an inch to 
one inch in width, so as to combine a certain degree 
of flexibility with the requisite firmness. 

The Turks use, according to Sedillot, in a similar 
manner, the "nervures" of palm laid upon sheep- 
skin and fastened with wooden thongs ; x and Dr. 
Packard mentions that he has seen narrow slips of 
some light wood glued in the same way upon soft 
pieces of buckskin, and then fastened together with 
two strips of buckskin, which were also glued to 
the splints. 2 

Common, unpolished pasteboard, cardboard, or 
the stout millboard used by bookbinders, constitute invaluable do- 
mestic resorts, since they can generally be found in the house of the 
patient ; and if in no other way, pasteboard may generally be had at 
the expense of some paper box or of the loose cover of some old book. 
For small bones, the thinner sheets afford a sufficient support ; but for 
large bones the thick binders' board is necessary. In preparing the 
latter for use, it ought to be moistened with water; but if soaked too 
much it will separate and fall into pieces, or lose its firmness when dry, 
in consequence of having parted with some of its paste. This splint 
may be applied to the limb without the interposition of anything but 
a few folds of muslin cloth, or a piece of flannel ; or we may use instead 
a single sheet of cotton wadding. It must be bound to the limb by 
the roller while it is moist, and as it dries speedily it forms a smooth, 
firm, and reliable splint. 

Felt, made of wool saturated with gum shellac, and pressed into 
sheets, makes an excellent moulding tablet for splints. This may be 
obtained at any hat manufactory. They are now manufactured, and 
moulded into a great variety of forms by Dr. David Ahls, at York, 
Pennsylvania. A much cheaper material, however, and which has 
nearly all of the qualities of the real felt, may be made from old 
pieces of broadcloth, or from any similar closely woven texture, by 
saturating it thoroughly with gum shellac, the gum being dissolved in 
alcohol in the proportions of one pound of the former to two quarts 
of the latter. Thus prepared, it is to be spread upon both surfaces of 
the cloth with a common paint brush. When this first coat is well 
dried by suspending the cloth where the air will have free access to 
both surfaces, a second must be spread upon one of the surfaces ; and 
then a third ; the cloth being allowed to dry after each successive coat. 
Finally, the sheet is to be folded upon itself, so as to bring the most 
thickly covered surfaces together, and pressed with a hot flat. 



1 Amer. Journ. Med. Sci., vol. xxiii., Feb. 1839, p. 481. 

2 Packard's edition of Malgaigue, vol. i. p. 173. 



52 GENERAL TREATMENT OF FRACTURES. 

If it is necessary to have greater strength, more gum may be laid 
upon the cloth, and it may be again folded and pressed. 

When used, it is to be dipped into boiling water or held near the 
fire until it becomes flexible. It hardens very rapidly in cooling, and 
demands, therefore, some quickness in its application ; but once ap- 
plied and fitted, it forms a hard but smooth splint well adapted for all 
the purposes for which it is designed. 

It is well to mention, if one wishes to keep any portion of the solu- 
tion which is not used, that in order to prevent evaporation the vessel 
in which it is contained must be closely covered. 

I have used this material for many years, both in hospital and pri- 
vate practice, and I can safely recommend it for all cases in which 
splints are required. The principal objection to all of those forms of 
splints which contain gum shellac is, that they harden so rapidly 
after being made flexible by exposure to heat, that it is often found 
difficult to give them an accurate mould to the limb. 

Dr. Jacobs says he has sometimes found an old hat to furnish a very 
efficient splint in the small fractures of children. 

It has been objected to the felt splint occasionally, that it is imper- 
vious to air and moisture, and that it confines the insensible perspira- 
tion ; an objection which may be obviated in some measure by rubbing 
the surface which is to be laid against the limb, with pumice-stone 
until it is roughened or until a short nap is raised. But as I never 
use splints of any kind without underlaying them with compresses 
which act sufficiently as absorbents, I have never been aware of any 
inconvenience from this source. 

Within a few years, sheets of gutta percha have been brought into 
the market, varying in thickness from one-sixteenth to one-quarter of 
an inch: the use of which for side splints, was first suggested and prac- 
tised by Oxley, of Singapore. For fractures of the thigh, and for the 
large bones generally, I prefer a thickness of about one sixth or one- 
fifth of an inch; but for the fingers or toes, it need not be more than 
one-sixteenth of an inch in thickness. In its natural state, and at the 
ordinary temperature of the body, it is nearly as hard and as inflexible 
as bone ; but when immersed in hot water it almost immediately 
softens, and would become too soft to be conveniently handled unless 
soon removed. It can therefore be adapted to any surface, however 
irregular, and its form may be changed as often as may be necessary. 
It does not harden as rapidly as felt, and it possesses, therefore, in this 
respect an advantage, since it allows the surgeon more time for adjust- 
ment; while, on the other hand, it hardens much more rapidly than 
either starch, paste, or dextrine. Ten or twenty minutes is all the 
time usually required for gutta percha to acquire that degree of firm- 
ness which will prevent it from yielding under the pressure of a 
bandage. 

To use it skilfully requires some experience, and I have known 
surgeons to reject it after a single trial; but by those who have ac- 
quired the necessary skill it is generally regarded as an invaluable 
resource. 

When constructing from this material a thigh splint, we should 



GENERAL TREATMENT OF FRACTURES. 53 

order a very large tin pan, or some open, flat tray, in which we may 
lay the splint at full length. If the splint is required to be twelve 
inches long, and six inches wide, we must cut it about sixteen inches 
long by eight wide, so as to allow for the contraction which always 
takes place more or less when the hot water is applied. It is then to 
be laid upon a sheet of cotton cloth of more than twice the width of 
the splint, in order that the cloth may envelop it completely when it is 
folded upon it ; and the cloth should be enough longer than the splint 
to enable us to handle and lift it by the two ends without immersing 
our fingers in the hot water. Beside, if the gum is not thus covered 
and supported, it will adhere to the vessel, to the fingers, to the surface 
of the limb, and indeed to whatever else it comes in contact with ; it 
may even fall to pieces, or become very much stretched and distorted 
by its own weight. The cloth cover will generally adhere to the splint, 
and may be permitted to remain upon it permanently. 

Place the splint, thus covered, in the basin, and pour on the water 
slowly. As soon as it is sufficiently softened, lay it over the limb, 
moulding it carefully with the hands, or by pressing it against the 
limb with a pillow. If it does not harden rapidly enough, this process 
may be hastened by sponging the outer surface with cold water; and 
as soon as it has acquired sufficient firmness to support itself it may 
be removed and immersed in a pail of cold water or placed under a 
hydrant; after this, it is to be neatly trimmed and wiped dry, when it 
is ready for use. 

When gutta percha remains a long time exposed to the air, it 
gradually oxidizes, its colour becomes darker, it loses its tenacity and 
flexibility. This may be prevented by keeping it constantly immersed 
in cold water. 

The same objection has been made also to gutta percha which is 
occasionally made to felt, namely, that it confines the perspiration, but 
to this we have already sufficiently replied. 

There is scarcely any fracture demanding the use of a splint in 
which I have not demonstrated its utility, but it is especially valuable, 
as I shall have occasion to mention again, as an interdental splint in 
fractures of the jaw, and as a moulding tablet in all fractures occur- 
ring in the vicinity of joints. 

Sheets of gutta percha of any required thickness may be obtained 
in this city, of Mr. Samuel C. Bishop, the manufacturer, at 113 Liberty 
Street. One pound will make about four thigh splints : the present 
price is about one dollar fifty cents per pound. 

Benjamin Welch, of Lakeville, Conn., has contrived a very ingenious 
application of gutta percha to the purposes of a splint, by veneering 
a thin plate of the gum with equally thin plates of elastic wood. The 
veneering is laid upon both sides, and then it is pressed into form in 
moulds. The elasticity of the wood, together with the plasticity of 
the gum, enables the surgeon to change its form somewhat at pleasure, 
by dipping it into hot water. 

Its form cannot, however, be changed to any great extent, and by 
frequent immersion in hot water the veneering is apt to loosen from 



54 



GENERAL TREATMENT OF FRACTURES. 



the gutta percha. 



Fig. 10. 



Nevertheless it is a most excellent splint, and in 
Yerj many respects it is superior to any 
of the carved wooden splints which we 
have ever seen. 

The moulding tablet of Alfred Smee, 
composed of gum Arabic and whiting, 
spread upon cloth, 1 has nothing special 
to recommend it, any more than the 
cloth splints, hardened with the whites 
of eggs and flour, used by Larrey. 2 
Starch and alum, glue, pitch, and vari- 
ous other materials of a similar character 
deserve only to be mentioned as having 
been occasionally employed, but which 
have never succeeded in securing for 
themselves the confidence of surgeons. 

In 1834, Seutin, of Brussels, intro- 
duced the use of starch as a means of 
hardening the bandages ; his method of 
using which is essentially as follows : a 
dry roller is first applied to the skin, 
and then smeared with starch; all of 
the bony prominences and irregularities 
of the limb are filled up or covered with 
cotton batting, charpie, down, etc.; strips 
of pasteboard, or of binders' board, 
moistened and covered also with starch, 
are now laid alongside the limb, over 
which again are turned in succession 
one, two, or three layers of the starched roller ; the number of rollers 
and the thickness of the pasteboard being proportioned to the size of 
the limb or to the required strength of the splint. The whole is com- 
pleted by starching the outside of the last bandage. 

This dressing will generally become dry within from thirty to forty 
hours ; which process may be expedited by exposing its sides as much 
as possible to the air, or by the application of artificial heat with bags 
of dry sand, or with hot bricks. As a temporary support until the 
drying is completed, some surgeons lay upon each side of the limb 
additional splints, securing them in place with tapes. 

As soon as the bandages are dry they are to be cut along the front 
to a sufficient extent to permit of an examination of the limb, and then 
closed with an additional roller. For the purpose of opening the 
bandages both at this period and subsequently, Seutin uses a pair of 
strong scissors or pliers, such as are represented in Fig. 11. 

On the third or fourth day, or as soon as the subsidence of the swell- 
ing may render it necessary, the bandages should be cut open through 




Starch bandage, applied for a broken 
thigh. 



1 Amer. Journ. Med. Sci., vol. xxvi. p. 220, May, 1840 ; from London Lancet, Jan. 
25, 1840. 

* Amer. Journ. Med. Sci., vol. ii. p. 216, May, 1828 ; from Journal des Progres, vol. iv. 



GENERAL TREATMENT OF FRACTURES. 55 

their whole extent, the edges pared off and brought together again 
snugly with an additional roller. 

Fig. 11. 




Seutin's pliers. 

Erichsen, who uses the starch bandage in all fractures and from the 
first day, advises that the limb shall be completely enveloped with 
cotton wadding before the first roller is applied ; in consequence of 
which he does not think it necessary to apply the first roller dry. 

Yelpeau prefers dextrine (" British gum") a kind of glue or jelly 
obtained by the continued action of diluted sulphuric acid upon starch 
at the boiling point. It is prepared for use by dissolving it in alcohol 
or tincture of camphor, or camphorated brandy, until it has acquired 
about the consistence of honey ; at this point hot water should be 
added, reducing its consistence to that of thin treacle, when, after one 
or two minutes' shaking, it is ready for application. According to F. 
D'Arcet, the proportions most favorable to the drying and solidifying 
of the apparatus are, one hundred parts of dextrine, sixty of cam- 
phorated brandy, and fifty of water. Malgaigne, to whom I am in- 
debted for this observation of D'Arcet, says, also, in a note, " as regards 
dextrine, an important point was recently brought practically under 
my notice, viz., that as sold in the shops, it is often unfit for making 
an agglutinative mixture ; it forms lumps with alcohol, as starch does 
with cold water, without cohering; and twice in succession I have 
been obliged to change the supply at the Hopital Saint Antoine. The 
dextrine thus deteriorated is whiter and less saccharine ; it crepitates 
more in the fingers ; and on pouring a few drops of tincture of iodine 
into the solution, there is produced a violet tint, indicating the pre- 
sence of fecula ; while true dextrine, treated with iodine, gives a vinous 
red, or the color of onion peel." 

Yelpeau soaks his bandages with the dextrine before applying them, 
but like Seutin, he applies his first roller dry. He uses but one band- 
age, which he carries first from below upwards and then from above 
downwards ; and he rarely thinks it necessary to employ the pasteboard 
as a collateral support. 

For myself I am quite as much in the habit of using wheat flour 
paste as either starch or dextrine, and if properly made, it dries about 
as quickly as the starch, and is equally as firm. 

Whatever material is used in the construction of what is now usually 
termed the " immovable apparatus," or, as Seutin has more lately called 
it, the "movable immovable apparatus" (" movo-amobile"), in reference 
to his practice of opening it at an early period, it is still the same 
apparatus in effect, and is liable to the same judgment — a judgment 



56 



GENERAL TREATMENT OF FRACTURES. 



which we shall find it very difficult to declare, since, from the day in 
which this practice was first recommended by Seutin, to the present 
moment, it has been constantly experiencing the most extraordinary 
vicissitudes in the public favor. At one time, and by the most ex- 
perienced surgeons, extolled as a method unequalled in its simplicity, 
efficiency, and safety, and at another, and by surgeons of equal experi- 
ence, denounced as eminently lacking in all of the true essentials of 
an apparatus for broken limbs. These conflicting opinions, which it is 
impossible to reconcile, have nevertheless some foundation in truth. 
The immovable apparatus, of whatever materials constructed, is under 
some circumstances a very simple, safe, and efficient dressing, while 
under other circumstances it is, as we think, eminently unsafe and ineffi- 
cient. Thus, in all of those fractures which are accompanied with such 
injury to the soft parts as to render subsequent inflammation inevitable 
or probable, this form of dressing exposes to congestion, strangula- 
tion, and gangrene. Whatever its advocates may say to the contrary, 
the simple fact is before us, that the number of accidents resulting 
from this practice is out of all proportion with any other yet introduced. 
I have met with them myself in all parts of my own country, and the 
journals abound with records of disasters from this source. 1 Nor is it 
a sufficient reply to this statement, that, with proper care and pru- 
dence, such accidents may be avoided. We think they could not 
always be avoided. But admitting that they could, it is still undenia- 
ble that in certain cases the immovable apparatus demands extraordi- 
nary attention ; and what is the need of multiplying our cares when 
already they are more than sufficient? Many circumstances, over 
which he has no control, may prevent the surgeon from giving to the 
limb the full amount of attention which is required ; and for this rea- 
son that apparatus is the best which, whilst it answers the indications 
equally well, exacts the least amount of skill and attention on the part 
of the surgeon. 

Fig. 12. 




Opening of the apparatus with Seutin's pliers. 



Immovable dressings are not only liable to become too tight as the 
swelling augments, but, on the other hand, the surgeon may omit to 



Amer. Jouru. Med. Sci., vol. xxv. p. 460, Feb. 1840; also vol. xxxi. p. 212. 



GEXEEAL TKEAT3IEXT OF FEACTUEES. 



57 



Fie. 13. 



notice that as the swelling has subsided it has become loose. Portions 
of the limb may vesicate, ulcerate, or even slough, without the know- 
ledge of the surgeon. If, however, the bandages are frequently opened 
and all the proper precautions are taken, it is possible that these acci- 
dents may also be avoided ; but unfortunately experience has shown 
that they have not been avoided in too many instances. 

The cases, then, to which this apparatus seems to be adapted, are a 
few examples of transverse or serrated fractures in which the bones 
have not become displaced, and in which little or no swelling is anti- 
cipated ; and certain fractures which were origi- 
nally more complicated, but in which a partial 
union, and the subsidence of the inflammation, 
have reduced them to a more simple condition; 
and especially is it adapted to cases of delayed 
union. If now the dressings are applied care- 
fully, the bandage being only moderately tight ; 
and a portion of the extremity of the limb is 
left uncovered so that we may observe con- 
stantly its condition, and at proper intervals the 
apparatus is opened completely, in order that 
we may subject the whole limb to a thorough 
examination; in such cases as we have now 
indicated and with such precautions, we admit 
that the "apparatus immobile" constitutes an 
invaluable surgical appliance, and one of which 
no surgeon can well afford to be deprived. 

I have even met with examples of compound 
fractures in which it has seemed proper to ap- 
ply this dressing; but only when a sufficient 
time had elapsed to render it probable that 
there w^ould be no sudden accession of swelling 
in the limb. In such cases I have preferred 
generally to lay the several turns of the roller 
directly over the suppurating wound in the 

same manner as if no wound existed, and to make a valvular opening, 
or window, with the scissors on the following day in order to allow 
the matter to escape, after w r hich the valve may be laid down and 
stitched, or the piece may be removed entirely, and a new piece of 
bandage drawn closely around the limb at this point. This may be 
repeated once or twice daily. If an opening is left by the roller, 
and no additional bandage is laid over it, the margins of the wound 
soon become oedematous and protrude, making an ugly-looking and 
ill-conditioned sore. 

Plaster of Paris moulds, employed occasionally from a very early 
period, and more lately recommended by Hendriksz, Hubenthal, Keyl, 
and Dieffenbach, are not entitled to serious consideration. Heavy stone 
coffins, they might serve well enough the purposes of interment, bat 
they are wholly unsuited to the purposes of a splint. 

Plaster of Paris has, however, been of late employed in another 
form, and in relation to which our judgment must be much more 




"Apparatus immobile" ap- 
plied over a compound frac- 
ture. 



58 GEXEEAL TEEATMEXT OF FEACTUEES. 

favorable. I allude to the so-called " plaster of Paris bandages," which 
were first introduced to notice by Mathiesen and Yan der Loo, of 
Holland, but the value of which has been more especially brought to 
notice by Prof. Nicholas PirogofY, of St. Petersburg, Surgeon-in-chief 
at Sebastopol, during the Crimean war. 

The manner of using the gypsum bandages is as follows : A dry 
roller is first applied to the limb, or it may be covered with a single 
piece of cloth of any kind, and the irregularities are filled up and pro- 
tected with cotton wool, the same as we have directed when about to 
apply the starch bandage. The remaining dressings being now at 
hand and ready for use, we proceed to mix the plaster. For this pur- 
pose we must select the fine, fresh, well dried, white powder. The 
gray does not solidify well, nor that which has been a long time 
ground, or is moist. The proportions of water and plaster usually 
required are about equal parts by weight. For the thigh it may re- 
quire, perhaps, seven or eight pounds of plaster, and for the leg or arm 
much less. It is probably a better rule to direct the gypsum to be 
added to the water until it is of about the consistence of cream. The 
water should be cold and the gypsum thrown in not too rapidly, at 
least not more rapidly than it can be thoroughly mixed, otherwise we 
shall not be able to determine precisely its consistence. If, while ap- 
plying the paste, it begins to harden in the bowl, we must not add more 
water, as this will again interfere with its final solidification upon the 
limb. It must be thrown away and some fresh immediately prepared; 
or the crystallization may be retarded by throwing in a few drops of 
carpenters' glue, or a little starch or dextrine ; but the piaster is apt 
to be brittle after the addition of these articles. When the plaster is 
good, and it is properly mixed, we may allow ourselves from five to 
eight minutes in the application. A large paint brush is the most 
convenient thing for spreading it, but the hands will do very well in 
an emergency. 

Everything being ready, the limb is to be seized by assistants at 
both of its extremities and held in a position of steady extension until 
the dressing is completed, and for one or two minutes longer, or until 
the plaster is hard. It will be sufficiently hard to support itself even 
when the dressings are quite moist. The surgeon then proceeds to lay 
a long piece of linen — old sack will answer as well as any — folded 
three or four times, and saturated with the paste, parallel to the two 
sides of the limb, around which are to be immediately placed horizon- 
tally and at several points, short and wide strips of the same material. 
These latter are intended to iocrease the strength of the apparatus, and 
to bind on the side strips. Finally, the whole may be painted with 
the solution. It is very well, however, not to cover the front of the 
limb, or a narrow strip somewhere in the line of the axis of the limb, 
with the plaster, as this will not diminish materially its strength, and 
it will enable the surgeon to open it more easily with the scissors. 
Pirogofi' accomplishes the same purpose by laying a piece of narrow 
tape, soaked in oil, along the line through which he wishes to make 
the section of the splint. 1 

1 Weber on Plaster of Paris Bandage. New York Journ. Med., May, 1856, p. 341. 



GENERAL TREATMENT OF FRACTURES. 59 

Another mode of applying the gypsum is to employ common rollers, 
made of unglazed, open calico. The cloth, being torn into strips of a 
suitable width and length, is laid upon a table, and the dry plaster 
rubbed into it for several minutes, until its meshes are well and evenly 
rilled. Each bandage is then rolled up closely, and immediately before 
being applied a little water must be dropped into the extremities of 
the roll to moisten the plaster, but not enough to soak through the 
plaster and thereby wash it out. Thus prepared, the gypsum roller is 
applied to the limb in circular turns, until the whole is completely en- 
cased with one or two layers. Eeversed turns must be avoided as far 
as possible, and when they become necessary, the fold should not be 
made over a projecting ridge of bone. 1 

At Bellevue Hospital we occasionally apply the plaster of Paris by 
a method which is very simple. The limb being carefully shaven is 
enveloped with one single sheet of coarse woollen cloth, which is pre- 
viously thoroughly saturated with the plaster. 

Dr. E. Harris, of this city, has ascertained that by mixing the plaster 
in the following proportions the weight will be considerably dimin- 
ished, namely, water 100 parts by weight, gypsum 75 parts, clear- 
boiled starch 2 parts. By this method the process of crystallization 
is retarded, and all the water, except about twenty per cent., is per- 
mitted to escape. 

For the use of the surgeons in the U. S. Army the Sanitary Com- 
mission furnished the plaster in tin cans hermetically sealed, but at a 
period too late to enable us to give it a fair trial in field practice. It 
is my impression, however, that this material is not well suited to the 
service of campaigns in this country, and that the opinions of foreign 
army surgeons as to its value must be taken with some allowance. 2 

Professor B. "W. Dudley, of Lexington, Ky., one of the most suc- 
cessful surgeons in this country, but especially distinguished as a 
lithotomist, has for many years employed in the treatment of fractures 
nothing but a roller, regarding both side splints and extending ap- 
paratus as not only useless but absolutely pernicious. 3 This practice, 
which seems to have originated with Radley, of England, has not 
found, hitherto, in this country or elsewhere, many imitators; and 
although one ought in general to speak very cautiously of a practice 
which he has never seen tried, and especially when it brings with it 
the authority of so 'distinguished a surgeon as Dr. Dudley, I do not 
hesitate to pronounce it irrational, and to declare my belief that it is 
in no way entitled to the confidence of the profession. 

Still more unscientific, and absurd even, is the practice of Jobert, 
of Paris, who employs neither side splints nor bandages, but only 
extension, in the treatment of all, or of nearly all fractures of the long 
bones. 

1 Gamgee's Researches, Loudon, 1856, p. 154. 

2 Practical Lectures on Military Surgery, by Isidor Gliick, of New York, chief sur- 
geon to the Hungarian (Vilmos) Hussars, &c. &c, during the late war in Hungary. 
Amer. Med. Monthly, Dec. 1855, p. 449, &c, vol. iv. New York Med. Times, Dec. 7, 
1861. 

3 Dudley, Trans. Arner. Med. Assoc, vol. iii., 1850, p. 349. 



60 GENERAL TREATMENT OF FRACTURES. 

The side or coaptation splints bring the fragments into more com- 
plete apposition, and secure a more prompt and certain union. They 
ought, therefore, never to be omitted unless the condition of the limb 
precludes their application. 

As to the question of permanent extension in fractures, and the 
means by which it may be most effectually accomplished, nothing- 
need be said at this time, inasmuch as it relates only to the fractures 
of certain bones, and to certain forms of fractures ; we must therefore 
refer its consideration to those chapters which treat of individual 
bones. 

In the treatment of comminuted fractures, no pains ought to be 
spared to bring the fragments as nearly as possible into apposition ; 
and if there exists at the same time an external wound, and the frag- 
ments are small and loose, they ought to be removed carefully. ISTor, 
indeed, should we be deterred from the attempt to remove them by 
finding that they are adherent, if still they are easily moved about 
with the finger. 

In compound fractures, not infrequently the end of one of the frag- 
ments protrudes from the wound, and its reduction may' be attended 
with considerable difficulty. My practice is usually in such cases to 
attempt the reduction first, by simple extension and counter-exten- 
sion ; but if this fails, I introduce my finger into the wound, and 
endeavor to stretch the skin over the sharp point of bone ; or I make 
use of a spatula formed from a piece of shingle, or of any suitable 
piece of metal which may be at hand ; finally, but not until all other 
expedients have failed, I enlarge the wound sufficiently to insure its 
return. 

There are some cases, however, in which the surgeon may feel 
justified in sawing off the projecting end; as when the periosteum is 
completely torn from it by its having penetrated a boot, or even some- 
times when its extremity is very sharp, and there is reason to suppose 
that it would prick and irritate the tissues. 

In a few of these cases, also, surgeons have proposed to secure the 
fragments in apposition by metallic ligatures or sutures. In a few 
instances the practice has been attended with success, but in most 
cases the wires have failed utterly of their purpose, and have only 
proved sources of additional irritation. 1 

If arteries bleed freely and for a long time, we may make some 
effort to find the open mouths in the wound, but in this we rarely 
succeed, nor is it prudent always to tie the main branch which supplies 
the limb. Fortunately, this bleeding, although at first profuse, gene- 
rally ceases in a few hours under the steady employment of cold lotions, 
moderate compression, and rest. If it does not, the chances are that 
the case will call for amputation. 

The rule generally laid down by surgeons that we should at once 
close the wound in compound fractures, with sutures and adhesive 
straps if necessary, or with bandages, is far too absolute. This prac- 
tice will do when there is no great contusion or extravasation of blood, 

1 Icarte, Journ. de Med., 1175, arid Laloy, Paris, 1839, from Holmes's Surgery. 



DELAYED AND NON-UNION OF BKOKEN BONES. 61 

but if blood is flowing, it is much better to leave the wound open so 
as to permit it to. escape freely ; and if the severity of the injury war- 
rants the supposition that much inflammation is to ensue, the danger 
of gangrene is greatly lessened by thus allowing the opening to remain 
as a channel of exit for the inflammatory effusions. 

Many years since Dr. J. Rhea Barton introduced into the Pennsyl- 
vania Hospital what has since been called the " bran dressing" for the 
treatment of compound fractures of the leg ; the limb being made to 
repose in a box filled with this material. 1 I have used it very fre- 
quently in Bellevue and in other hospitals, and can speak of it as 
possessing many qualities of excellence, especially as a summer dress- 
ing. The particular mode of using this apparatus I shall describe 
more minutely when treating of fractures of the leg. 

The treatment of inflammatory symptoms, and of the later accidents, 
such as suppuration, oedema, gangrene, tetanus, &c, must be left mainly 
to the good judgment of the surgeon. Gentle manipulation, uniform 
support, rest, and sometimes cooling lotions constitute the most impor- 
tant means by which inflammation is to be controlled. Bleeding is 
rarely necessary, and in a large majority of cases it might prove 
injurious by lowering too much the vital forces, which need to be 
husbanded in view of the requirements of the process of repair and of 
the long and exhausting confinement. Cathartics should also be 
administered cautiously for the same reason, and because they are 
liable, especially in fractures of the lower extremities, to occasion a 
serious disturbance of the limb. 



CHAPTE& VI. 

DELAYED UNION AND NON-UNION OF BROKEN 

BONES. 2 

Most surgical writers concur in the statement that non-union of 
broken bones is an uncommon event. Walker, of Oxford, affirms 
that of not less than one thousand fractures which have come under 
his treatment at some period of the repair, he does not recollect more 
than six or eight instances. According to Lonsdale, not more than 
five or six cases of false joint, excepting those within a capsule, have 
occurred out of nearly four thousand fractures treated at the Middle- 
sex Hospital. In a table of 367 cases, collected and arranged by W. 
W. Morland, from the books of the Massachusetts General Hospital, 

1 Paper on Bran Dressings, by Reynell Coates, of Philadelphia. Amer. Journ. Med. 
Sci., April, 1842, p. 515 ; from the Med. Examiner, Nos. 9 and 11, vol. L, New Series. 

2 I shall, in this chapter, avail myself freely of the labors of George W. Norris, of 
Philadelphia, whose paper, entitled "On the Occurrence of Non-union after Fractures, 
its Causes and Treatment," published in the American Journal of Medical Sciences for 
Jan. 1842, constitutes the most complete and reliable monograph upon this subject 
contained in any language.- 



62 DELAYED AND NON-UNION OF BROKEN BONES. 

extending through a period of nineteen years, only one example of 
false joint is recorded ; but as only seventy-four days had elapsed 
when this patient was discharged, it is doubtful whether this might 
not have proved to be a case of delayed union simply. 1 In 946 cases 
of recent fracture treated in the Pennsylvania Hospital between the 
years 1830 and 1840 there was no instance of false union. 2 Sir Stephen 
Hammick, Mr. Liston, and Malgaigne affirm also the infrequency of 
these accidents in the cases which have come under their personal 
treatment. I have myself seen a considerable number of examples 
of non-union, but in not one of my own patients, whether in hospital 
or private practice, except in cases involving joints, has the bone re- 
fused finally to unite; and my opinion is, that in proportion to the 
number of fractures everywhere, these cases are very rare, perhaps 
not in a larger proportion than one in five hundred. 

Amesbury alone seems to have entertained a contrary opinion, 
his own experience having supplied fifty-six examples of what he has 
called "fractures of long standing." I notice, also, that at a later 
period Mr. Amesbury 's experience in false joint extended to ninety 
cases. 

The humerus and femur would appear to be the bones most liable 
to non-union, as shown by Norris's statistics ; in which forty-eight be- 
longed to the humerus, forty-eight to the femur, thirty-three to the leg, 
nineteen to the forearm, and two to the jaw. In my own experience, 
I have found the humerus ununited much more often than the femur. 

Berard has shown that in the growth of the long bones the period 
at which the epiphyses are united to the diaphyses depends upon the 
direction of the nutritive artery; for example, "it is found that in the 
humerus, where the direction of this vessel is from above downwards, 
consolidation takes place soonest at its inferior extremity. In the fore- 
arm, the course of the nutrient vessels is from below upwards, and 
here consolidation of the epiphyses is found to occur at the elbow 
sooner than at the wrist. In the inferior members, on the contrary, 
the epiphyses composing the knee are the last which become firm, 
because in the femur the nutritious artery runs upwards, and in the 
bones of the leg it courses from above downwards." A knowledge of 
these facts led Gueretin to inquire into the influence of these arteries 
upon the consolidation of fractures; and the cases collected by him 
did indeed seem to show a positive relation between the direction of 
the artery and the union of the bone ; that is to say, the examples of 
non-union were chiefly found where the fracture had taken place on 
that side of the nutritious foramen from which the artery entered, as 
if to imply that the non-union was in some measure due to the imper- 
fect nutrition of this extremity of the bone. In thirty-five cases of 
non-union analyzed by Gueretin, ten belonged to that portion of the 
bone which was traversed by the artery, and twenty-five to the other 
portion. But an analysis of forty-one cases, made by Norris, does not 
seem to confirm this observation of Gueretin, since twenty-seven were 

1 Address on Fractures, by A. L. Peirson, read before the Massachusetts Med. Soc. 
May 27, 1840. 

2 Norris, loc. cit. 



DELAYED AND NON-UNION OF BROKEN BONES. 63 

in the direction of the nutritious arteries, and only fourteen in the 
opposite portion, or in that which is supposed to be less nourished. 

Another observation, made by Curling, that in fractures of the long 
bones the portion below the entrance of the nutrient artery, or on that 
side of the nutrient foramen towards which the blood flows, being 
defrauded of its proper supply, is subjected to a species of atrophy, 
presenting a larger medullary canal, with thinner walls, and a spongy 
tissue less dense, also needs confirmation. Malgaigne has not noticed 
this fact in any of the specimens contained in the public museums of 
Paris ; and we do not know that any other writer has made the ques- 
tion a subject of especial inquiry. 

According to ISTorris, there are four principal kinds of false joint: — ■ 

In the first, the bones are united and completely enveloped in a car- 
tilaginous mass or callous tumor, but in consequence of some retarda- 
tion in the process bony matter is not deposited, and, as a consequence, 
it wants solidity, the part continuing easily movable. This may be 
regarded as a proper example of delayed union, as distinguished from 
complete non-union, or false joint. 

In the second, there is entire want of union of any sort between 
the fragments, the ends of which seem to be diminished in size and 
extremely movable beneath the integuments. The limb in these cases 
is found wasted and powerless. 

In the third and most common class, the medullary canal is oblite- 
rated in both fragments, and the ends 
are more or less absorbed, rounded, g * 14, 

with a dense tissue resembling the f^P^-^^^^^NtB^Jr*^^^ 
periosteum. A connection also exists m . . , . .. ^ ^^ 

i: . . . Clavicle united by ligamentous bands. 

between the opposing fragments m 

the form of strong ligamentous or fibro-ligamentous bands, which, if 
of any length, are quite flexible, and allow of considerable motion at 
the seat of fracture. 

In the fourth, "a dense capsule without opening of any kind con- 
taining a fluid similar to synovia, and resembling closely the complete 
ligaments, is found." In these cases the points of the bony fragments 
corresponding to each other, are rounded, smooth, and polished, in 
some instances eburnated, and in others covered with points or even 
thin plates of cartilage, and a membrane closely resembling the syno- 
vial of the natural articulation. It is in this kind of cases, Norris 
remarks, that the member affected may still be of use to the patient, 
the fragments being so firmly held together as to be displaced only 
upon the application of considerable force. 

The existence of these newly-formed joints, or true diarthroses, 
has been called in question by Boyer, Hewson, Chelius, 1 and others; 
but the observations of Sylvestre, Brodie, Beclard, Home, Howship, 
Otto, Kuhnholtz, Houston, Cooper, Langenbeck, and Breschet prove 
that such examples are occasionally found. 2 

1 Malad. Chirurg.,t. iii. p. 103, Paris, 1831 ; North Araer. Med. and Surg. Journ., No. 
ix. p. 7, 1828 ; Trait, de Chir., trad, par Pigne, p. 150, 1836. (Norris, loc. cit ) 

2 Nouvelles de la Repub. des Lettres de Bayle, p. 718, 1685 ; Lond. Med. Gaz., xiii. 



61 DELAYED AND NON-UNION OF BROKEN BONES. 

Norris is a disciple of Dupuytren, and accepts his doctrine of the 
formation of callus without reservation ; consequently he finds no ne- 
cessity for bat one form of delayed union, namely, that which we have 
described as belonging to the first class. In all of this class he assumes 
the existence of a cartilaginous ring or ferrule ; but we think the error 
of this exclusive theory has been sufficiently shown by the observa-. 
tions of Paget and others, and we should be warranted therefore in 
affirming the existence of as many varieties of delayed union as there 
are varieties in the manner and position of the deposit of callus, even 
if their actual existence had not been repeatedly demonstrated by 
dissections. 

The causes of delayed union and of non-union are either constitu- 
tional or local. 

The constitutional causes are chiefly those conditions of the general 
system which manifest themselves by anaemia, debility, or some pecu- 
liar dyscrasy. 

Sanson, Beulac, Condie, 1 and many others have mentioned cases in 
which the existence of syphilis in the system has seemed to prevent 
the formation of callus: but on the other hand Lagneau and Oppen- 
heim 2 incline to the opinion that syphilis exerts in this respect but 
little influence ; and even Berarcl, who admits the pertinence of one 
case observed by Mcod, concludes, after numerous researches, that it 
has been very rarely shown to affect the formation of callus. 3 

Pregnancy and lactation have been known to interfere with the union 
of bones. Werner, Hildanus, Wilson, Hertodius, Alanson, Bard, of 
New York, and Condie, of Philadelphia, 4 have all reported examples, in 
some of which the process of union was resumed and brought to a 
rapid completion so soon as the period of pregnancy was closed, or 
when lactation ceased ; but three cases reported by Sir Stephen Love 
Hammick would seem to show, what, indeed, other evidences render 
probable, that the delay was less due to the fact of the pregnancy and 
the lactation than to the debility occasionally consequent upon these 
conditions. 5 

As to the question whether cancer ever causes a delay in the union 
of bones, Norris declares, that after a very careful examination of what 
has been written upon this subject, it is his opinion that where the 
fracture arises in consequence of a true cancerous deposit around, or in 
the interior of the bones, producing absorption of their tissue, no union 

p. 57,1833 ; Beclard, Gen. Anat., trans, by Hay ward, pp. 149, 248 ; Transac. Med.-Chir. 
Soe. of Edinburgh, i. p. 233, 1793; Med.-Chir. Trans., viii. p. 517, 1S17 ; Otto's Path. 
Anat., trans, by South, i. p. 138 ; Journ. Complement., iii. p. 291 ; Dub. Med. Journ., 
viii. p. 493; Cooper on Frac. and Disloe, fourth London ed., p. 508 ; Recherch. sur les 
Formation du Cal, 1819, p. 34. (Norris, loc. cit.) 

1 Diet, de Med. et Chir. Prat., iii. p. 492 ; Journ. de Med. Chir. et Pharm., t. xxv. 
p. 216. (Norris, loc. cit.) 

2 Expose des symp. de la mal. Ven., p. 525 ; Oppenheim on False Joints, 1837. 
(Norris, loc. cit.) 

3 Op. cit., p. 21. 

4 Cooper's Die, ed. 1838, p. 546 ; Opera Hild , 1681 ; Wilson on the Human Skele- 
ton, p. 214; Bib. Choisie de Med., xxiv. p. 595; Med. Obs. and Inquiries, 4, 1772; 
Phi'lo*oph. Trans., xlvi. p. 397, 1750. (Norris, loc cit.) 

5 Practical Remarks on Amputations, Fractures, &c, p. 121. (Norris, loc. cit.) 



DELAYED AND NON-UNION OF BKOKEN BONES. 65 

takes place ; but where, as is usually the case, the fracture is due to a 
fragility of the bones, occasioned by what Mr. Curling has denominated 
eccentric atrophy, it will be found to unite readily. Parker, of New 
York, relates the case of a girl only fifteen years of age, in whom the 
femur was broken from a very trivial cause ; and in which case the 
autopsy, made at the end of five months from the time of the accident, 
furnished some confirmation of these views. The place of fracture 
was occupied by an irregular encephaloid mass. It is curious, how- 
ever, that in this case, the callus was actually formed at first, and the 
bone seemed to be well united at the end of five weeks ; but at the 
time of the autopsy no callus existed. 1 

Scurvy, fevers of a low type, and, on the other hand, fevers of a 
highly inflammatory character, profuse uterine and vaginal discharges, 
and rachitis, conduce to the same result. 

The withdrawal of a habitual stimulus, and especially a change 
from a good to a low diet, or copious bleedings may either of them 
delay the deposit of ossific matter, or prevent it altogether. 2 

Bonn has furnished two cases in which advanced age seemed to 
have retarded the formation of callus, but Horner saw a fracture of the 
humerus in a woman ninety years old, unite in five weeks. 3 I have 
myself noticed a good many similar examples in advanced life, and 
it is now rendered quite probable that surgeons have generally over- 
estimated the influence of age upon the formation of callus. 

The local causes are, arrest of the arterial circulation by bandages, 
splints, &c, a perineal band, or an axillary pad may accomplish the 
same result ; paralysis or impairment of the nervous circulation, the 
occurrence of the fracture within a capsule, obliquity of the fracture, 
overlapping of the fragments, interposition of a piece of bone, of a 
tendon, muscle, or of a clot of blood, or separation of the fragments 
from any cause whatever, erysipelas, acute phlegmonous inflammation, 
suppuration, necrosis, too much motion, compression, exclusion of light 
and air inducing local scurvy, wet and especially cold and moist 
dressings, too early use of the limb, &o. 

In order to hasten the consolidation when it is simply delayed, we 
resort to all of those expedients which are calculated to invigorate the 
general system ; and for this purpose the employment of a nutritious 
diet and the use of mineral or vegetable tonics may not be properly 
omitted; but in our experience nothing has proved so efficient as 
encouraging the patient to leave his bed and get out into the open air; 
for which purpose, if the fracture is in the lower extremities, crutches 
will be necessary. 

As local means we may enumerate first the removal of those local 
causes which seem to have interfered with the consolidation or with 
the union. If the fragments have been officiously disturbed, it may 
be sufficient to impose upon the limb absolute rest for a certain length 
of time; and the fragments may be more closely pressed against each 
other ; in other cases it will be found necessary to remove the bandages, 

1 Parker, New York Jotira. Med., July, 1852, p. 97. 

2 Norris, loc. cit. s Ibid., p. 29. 



DELAYED AND NON-UNION OF BROKEN BONES. 



expose the limb freely to the light and air at least once or twice daily, 
and to rub it gently with the dry hand or with some moderately stimu- 
lating oil, so as to induce a more healthy condition of the soft parts, 
and encourage the natural circulation. 

Moving the fragments freely upon each other, sufficient to determine 
a degree of excitement in the adjacent tissues, and upon the opposing 
surfaces of the bones, and then confining them during one or two 
weeks in firm and well-fitting splints, will often succeed when other 
means have failed. 

Indeed I may say that by one or another of the simple methods 
now enumerated I have never failed sooner or later to effect consolida- 
tion, in recent fractures; and it has only been in fractures of at least 
four, six, or eight months' standing that I have been compelled to re- 
sort to more extreme measures. 

As a means of combining immobility with compression and health- 
ful exercise, the "apparatus immobile," in many of its forms, is pecu- 
liarly adapted. White, of Manchester, employed a firm leather sheath 

for the thigh. H. H. Smith, of Phila- 
delphia, recommends a more complex 
artificial support, upon which the 
limb may be allowed to rest while 
in the act of progression. 1 With 
some surgeons the object of allowing 
the patient to walk in fractures of 
the thigh or leg, is chiefly to excite 
in the tissues adjacent to the seat of 
fracture some degree of inflammatory 
action, but which, as the result in one 
of White's patients has sufficiently 
shown, may be carried too far, and 
even determine a suppuration. 

Dr. E. R. Hudson, artificial-limb 
maker, of New York, has applied in 
similar cases an apparatus of his own 
construction, made of willow, and 
secured in place by leather straps. 
In case the purpose of the apparatus 
is to encourage bony union, no motion 
is allowed at the knee-joint. 

Blisters, mustard cataplasms, the 
tincture of iodine, 2 caustics, 3 &c, 
applied externally over the seat of 
fracture, can have no other effect than 
to increase moderately the congestion 
of the tissues, and in so far they may 

Hudson* splint for ununited fractures of femur, . . ' , r> i i 

accompanied with shortening of the limb. aid 1U the aCCOmpllSHment Ol the DOliy 




1 H. H. Smith, Amer. Journ. Med. Sci., Jan. 1855. 

2 Hartshorne, Eclectic Rep., vol. iii. p. 114, 1813. 

3 Willougkby, Am. Journ. Med. Sci., Aug. 1834, p. 444. 



DELAYED AND NON-UNION OF BKOKEN BONES. 



67 



Fig. 16. 



union; but in this respect they are inferior to the violent twistings, 
flexions, and rubbiDgs of the broken ends of which we have already 
spoken. 

Electricity was first employed by Mr. Birch, of London, but Dr. 
Mott obtained no effect from it in two cases where he seems to have 
given it a fair trial. 1 Lente, of the New York Hospital, has more re- 
cently furnished an account of three cases treated in that institution 
by electricity in connection with acupuncturation; the mode of using 
which was to pass a needle down to the periosteum on each side of the 
bone, and to attach the poles of the battery to these opposite points. 
Lente thinks that electricity employed in this way is much more effi- 
cient than when the poles are merely applied to 
the surface. He informs us also that other cases 
than these now reported have been treated suc- 
cessfully in this hospital by means of electricity. 2 

Mercury, urged to ptyalism, will no doubt prove 
serviceable occasionally by virtue of its powers 
as an anti-syphilitic, but its beneficial influence 
in other cases is far from having been established. 

The seton is said to have been first suggested 
by Winslow, in 1787; but what is of much more 
consequence, the credit of its first successful ap- 
plication and its general introduction into practice, 
is due to Dr. Philip Syng Physick, of Philadel- 
phia, by whom it was employed in 1802. 3 

Physick used for his seton, generally, silk rib- 
bon, or French tape; and this he introduced by 
means of a long seton needle, between the ends 
of the fragments. He recommended that the 
seton should remain in place four or five months, 
and longer if necessary, and it was his opinion 
that the failures were generally due to its being 
removed too early. At the present day, however, 
surgeons who employ the seton think it serves its 
purpose better when it remains in place but a 
few days, not longer, perhaps, than ten or fifteen, 
always taking care that it is removed before ex- 
cessive suppuration is induced. It has been found 
especially valuable in fractures of the inferior 
maxilla, clavicle, and upper extremity generally ; 
but in the case of the femur, it has so frequently 
failed that Dr. Physick himself did not recom- 
mend its use. 

In case the seton cannot be passed directly 
between the opposing fragments, as recommended by Physick, we 
may adopt the practice suggested by Oppenheim, and carry two setons, 
one on each side, close to the bone. 




Physick's first case, after 
28 years. (From Am. Journ. 
Med. Sci.) 



1 Mott, Med. and Surg. Rep., p. 21, p. 375. 

2 Lente, New York Journ. Med., Nov. 1850, p. 317. 

3 Physick, Med. Repository of New York, vol. i. 1804. 



DELAYED AND NON-UNION OF BROKEN BONES. 



Fig. 17. 



Somme, of Antwerp, preferred a loop of wire to the silk seton 
employed by Physick. 1 Seerig passed a ligature around the liga- 
mentous mass connecting the two fragments, and then proceeded to 
tighten the ligature until it fell off. 2 Dr. Hulse, of the U. S. Navy, 
employed stimulating injections with success in a case of non-union, 
accompanied with an external and fistulous opening. 3 In 1848, 
Dieffenbach recommended that ivory pegs be introduced into holes 
previously made in the bone, 4 by means of a gimlet or drill, and Mr. 
Stanley has succeeded once by this method. 5 

Malgaigne, in 1837, tried to introduce acupuncture needles between 
the ends of an united fracture, but although he thrust the needle 
down to the bone thirty-six times, he was unable to make it pass once 
between the ends of the fragments. 6 Wiesel succeeded better. In a 
case of ununited fracture of the ulna of nine weeks' standing, having 
passed two needles between the fragments, at the 
end of six days, the needles being removed, con- 
solidation rapidly ensued. 7 This practice does 
not differ essentially from the metallic loop of 
Somme. It is only a modification of the seton. 
Brainard, of Chicago, has attempted to show 
that setons of any kind, whether of wood, ivory, 
or metal, placed in contact with the bone, occa- 
sion absorption, caries, and necrosis, but that 
they never directly give rise to bony callus; and 
that the occasional success of the seton, which 
success he believes to have been greatly exag- 
gerated, has not resulted from anjr tendency to 
favor the formation of callus, but from the indu- 
ration and tenderness of the soft parts produced 
by it ; circumstances which, by conducing to rest, 
indirectly favor the consolidation. 8 

In May, 1848, Miller, of Edinburgh, reported 
five cases treated successfully by subcutaneous 
puncture. The operation consisted in passing 
the point of a needle or small tenotomy bistoury, down upon the ends 
of the bone, and freely irritating the surfaces at several points. 9 
George F. Sandford, of Davenport, Iowa, has successfully imitated 
this practice in two cases. 10 

In 1850 Dr. William Detmold, of New York, performed the opera- 
tion of drilling or perforating the fragments in a case of ununited 



Dieffenbach' s drill for un 
united fracture. 



1 Amer. Journ. Med. Sci., vol. vii. p. 497. 

2 Norris, loc. cit., p. 46. 

3 Hulse, Amer. Journ. Med. Sci., vol. xiii. p. 374. 

4 Malgaigne, trans, by Packard, op. cit., p. 258, note. 

5 Stanley, New York Journ. Med., Nov. 1854, p. 441, from Dublin Press. 

6 Malgaigne, op. cit. 

7 Wiesel, Amer. Journ. Med. Sci., vol. xxxiv. p. 254, July, 1844. 

8 Brainard, Trans. Amer. Med. Assoc, vol. vii., 1854: Prize Essay. Report on 
Surgerv to Illinois State Med. Soc, Mav, 1860. 

9 Miller, New York Journ. Med., July, 1848, p. 134. 

10 Sandford, Trans. Amer. Med. Assoc, vol. iii. p. 355, 1850. 



DELAYED AND NON-UNION OF BROKEN BONES. 



69 



fracture of the tibia, emploj-ing for this purpose a large gimlet. He 
first bored two holes between the opposing fragments, and then, intro- 
ducing the gimlet one and a half inches below the fracture, he pene- 
trated the tibia upwards and inwards until he had traversed, also, the 
upper fragment to the extent of an inch. In three weeks the bone 
appeared firm, but from this time the patient was not seen. 1 

Brainard employs for this same purpose a strong metallic perforator, 
consisting of a handle, into which points of different sizes may be in- 
serted, and which have been hardened so as to penetrate the hardest 
bone or even ivory in every direction easily. The points are "some- 
what awl-shaped; but more pointed in the middle rather than like a 
drill, which leaves chips.'' His manner of using this instrument is as 
follows : " In case of an oblique fracture, or one with overlapping, the 
skin is perforated with the instrument at such a point as to enable it 
to be carried through the ends of the fragments, to wound their sur- 
faces, and to transfix whatever tissue may be placed between them. 
After having transfixed them in one direction, it is withdrawn from 
the bone, but not from the skin, its direction changed, and another 
perforation made, and this operation is repeated as often as may be 



Fig. 18. 



< ^22 




Brainard's perforator, reduced one-half. 

desired." Dr. Brainard, who has already succeeded by this procedure 
in a number of cases of ununited fracture, thinks it is better to com- 
mence in most cases with not more than two or three perforations, in 



Fig. 19. 



£a 




Bone drill. 



order that the effect produced shall not be too severe. It is scarcely 
necessary to add that, after the punctures have been made, the limb 
should be put completely at rest in appropriate splints, or in apparatus 
of some kind. 

1 New York Med. Gazette, Oct. 12, 1S50. 



70 DELATED AND NON-UNION OF BROKEN BOXES. 

Mr. Tieraau has made for me a bone drill which is rotated by the 
movement of a handle upon a rod ; or shaft, composed of twisted wire, 
and which possesses the advantage of being worked with great facility 
and rapidity. Perforators of any size or shape may be fitted to the 
shaft at pleasure. (Fig. 19.) 

Scraping or rasping the ends of the bones is a practice which dates 
from a very early period. Mr. Brodie scraped the ends of the bones, 
and then interposed a bit of lint. 1 Mayor, in 1828, contrived to intro- 
duce an iron, previously heated in boiling water, through a canula, 
and thus brought the heat to bear directly upon the ends of the frag- 
ments; and by repeating the application several times a cure was 
effected. 2 

Resection of the ends of the bones, first brought into notice by White, 
of Manchester, in 1760, 3 and opposed .by Brodie 4 as dangerous, and 
by Malgaigne regarded as generally useless or unnecessary, has still 
been practised a great number of times with more or less success. It 
is especially applicable to superficial bones, and in cases where the 
bones overlap. 

Roux practised resection in one instance, and then managed to en- 
gage the point of one of the fragments in the medullary canal of the 
other. 5 

White, of Manchester, Henry Cline, of London, Hewson, Barton, 
and Norris of Philadelphia, have applied caustics directly to the ends 
of the fragments, after having exposed them by a free incision. 6 Petit 
applied the actual cautery. 7 

Tying the fragments together by means of metallic ligatures, is as 
old as the days of Hippocrates ; but in 1805 Horeau adopted the same 
procedure in a case of ununited fracture. 8 J. Kearney Rodgers, Mott 
and Cheeseman, of Kew York, Flaubert, of Rouen, 9 and N. R. Smith, 
of Baltimore, 10 have repeated the operation with complete success. 
The operation is, however, not without its hazards. Norris has seen 
one case in which a broken patella was wired together, and a fatal 
result followed on the fourth day. 

E. S. Graillard, of Richmond, Va., proposes to secure the fragments 
in place by means of a metallic pin. The instrument which he 
employs is composed of a steel shaft with a handle, a silver sheath, 
and a brass nut. For a broken femur, the shaft is six inches long, its 
lower extremity being constructed like a gimlet, while two and a half 
inches of its upper extremity are cut for a male screw, being intended 
to carrj- the brass nut. The sheath is three inches long. 

Through an incision made over the seat of fracture the sheath, 
detached from the shaft, is carried down to the bone. The shaft is then 
passed through the sheath and made to penetrate and transfix the two 
fragments ; as soon as this is accomplished the nut is turned down 

1 Brodie, Lond. Med. Gaz., July, 1834. 2 Norris, loc. cit.. p. 48. 

3 Diet, de Med., vol. xiii. p. 503. 

4 Brodie, New York Journ. Med., vol. viii. 1st ser., p. 133. 

5 Norris, loc. cit., p. 49. 6 Ibid. ' Ibid. s Ibid. 
9 Rodgers, New York Journ. Med., vol. i. 1 ser.. p. 343, 1839. 

10 Note to Packard's Trans, of Malgaigne, p. 255. 



DELAYED AND NON-UNION OF BKOKEN BONES. 71 

firmly upon the top of the sheath and apposition of the fragments is 
thus secured. The whole instrument is permitted to remain until bony 
union is effected. 1 

Fig. 20. 



-ogSS&..' i ^fe^^ , =g^ 



Gaillard's instrument for ununited fractures. 




Finally, having thus brought rapidly before us all of the various 
modes of treatment which have been suggested and practised for non- 
union of broken bones, we are prepared to affirm the following con- 
clusions, or summary of what has been our own practice, and of what 
we believe ought to be the general course of procedure in these 
cases : — 

First. Improve the condition of the general system. 

Second. .Remove as far as possible the local impediments, such as a 
separation of the fragments, local paralysis, local scurvy resulting from 
long exclusion from light and air, congestions, &c. 

Third. Increase the action of the tissues immediately adjacent to 
the fracture, upon which tissues rather than upon the bone, as Mal- 
gaigne thinks, the formation of callus depends. A theory which, as 
applied to old and ununited fractures, we are not prepared to deny. 
This may be accomplished by frictions, and violent flexions of the 
limb at the seat of fracture ; possibly in some measure by the applica- 
tion of vesicants or of other stimulants, to the skin itself. 

Fourth. Employ again compression and rest for a period of from 
two to four or eight weeks. 

Fifth. Resort to the methods recommended by Brainard or by Gail- 
lard. 

Sixth. If in the lower extremity, allow the patient to walk about 
with the fragments well supported. 

Seventh. If the fracture is not in the femur, and as an extreme 
measure, employ the seton. 

Eighth. Resection is applicable only to superficial bones, and in 
cases of overlapping. 

Where these measures have failed, after a fair trial, we should either 
abandon the case as hopeless, only supporting the limb by such appa- 
ratus as may be found most serviceable, or we should recommend 
amputation. 

1 E. S. Gaillard, New York Journ. Med., Nov. 1865. 



72 BENDING- OF THE LONG BOXES. 



CHAPTEE VII. 

INCOMPLETE FRACTTJEES. 

BENDING, PARTIAL FRACTURES, AND FISSURES OF THE LONG BONES. 

§ 1. Bending of the Long Bones. 

Strictly speaking, no bone can be much bent without being also 
more or less broken, and that whether it immediately and spontane- 
ously resumes its position or not ; for, if the bending and straightening 
of the bone be repeated a sufficient number of times, the yielding of 
the fibres will become apparent, and at length the separation will be 
complete. The first of this series of flexions was quite as much re- 
sponsible for this result as the last, and, no doubt, performed its share 
in the production of the complete fracture. 

There could be no impropriety, therefore, in speaking of a bending 
of the bones as a variety of incomplete fractures, as I have done in 
the first section of my " Eeport on Deformities after Fractures," made 
to the American Medical Association in 1855. 1 

They have been called, not inappropriately, interperiosteal fractures, 
since in these cases the periosteum is not broken ; M. Blandin thinks 
that the outer and semi-cartilaginous laminae of the bone also do not 
break, while the deeper laminae suffer an actual disruption. 2 But it 
is quite as probable that in a majority of cases the true pathological 
condition is a compression of the bony fibres upon one side, with a 
corresponding expansion upon the opposite side, with only a slight 
interstitial fracture, too trivial to be easily recognized even in the dis- 
section. Sometimes, as I have several times observed in my experi- 
ments on the bones of chickens, when the bones are small, and the 
bending is near the centre of the shaft, the whole of the laminae on 
the side of the retiring angle produced by the bending are doubled in, 
or indented toward the hollow of the bone, so that the fibres on the 
side of the salient angle are not even stretched, and much less broken. 
In such cases, the interstitial disruption, if it exists at all, and I think 
it does, first takes place in the deeper layers of the retiring angle. 

I might, therefore, feel justified in continuing to call these cases 
partial fractures, or, perhaps, interstitial fractures, but I believe that 
the whole subject will be rendered more intelligible if I call them 
simply bending of the bones, as distinguished from those other and 
more palpably partial fractures of which I shall speak presently. 

« Op. cit, pp. 421—422. 

2 Markham's Obs. on the Surg. Practice of Paris, London Med.-Chir. Rev., vol. 
xxxiv. p. 473, 1841. 



BENDING OF THE LONG BONES. 73 

1. Bending with an immediate and spontaneous restoration of the hone 
to its original form. — The possibility of this accident, to which, however, 
surgical writers have hitherto made no distinct allusion ; is rendered 
certain by the following experiments: — 

Experiment 1. — July 16, 1857. I bent the tibia of a Shanghai 
chicken, four weeks old, at about the middle of the bone. It was bent 
to an angle of quite twenty -five degrees, but it was not felt or heard 
to break. It immediately and spontaneously resumed the straight 
position. 

July 18, two days after the bending, I dissected the limb, and found 
no trace of the injury, either within or without the bone, unless I 
except a very minute blood-clot in the centre of the shaft. 

Experiment 2. — I bent the leg of a chicken, four weeks old, at the 
same point and to the same degree. It immediately resumed the 
straight position. 

Dissection after two days. Nothing abnormal except a small blood- 
clot in the centre of the bone, and a slight disorganization of the 
medulla. 

Experiments 3 and 4. — Bent both legs of a chicken, four weeks old, 
at the same point, and in the same manner. They immediately re- 
sumed their positions. 

Dissection after two days. No lesions or morbid appearances which 
I could detect. 

Experiments 5 and 6. — Bent both wings of a chicken four weeks 
old. Bent the right wing to an angle of thirty-five degrees. I did 
not feel them break. Both resumed their positions spontaneously. 

Dissection after two days. No lesions or other morbid appearances. 

Experiment 7. — July 16, 1857, 1 bent the leg of a Shanghai chicken, 
five weeks old, below the knee, and at about the middle of the bone. 
It was bent to an angle of about twenty -five degrees, but the bone was 
not felt or heard to break. It immediately and spontaneously resumed 
the straight position. 

July 20, four days after the bending, I dissected the leg, but could 
not discover the slightest trace of the injury, unless it be that there 
was a very minute ossific deposit in the centre of the bone, at the point 
at which I suppose it to have been bent. 

Experiment 8. — July 16, 1857, I bent the right leg of a Shanghai 
chicken, five weeks old, at the same point as in the first experiment, 
and to the same extent. The bone did not seem to break, but it 
immediately and spontaneously resumed the straight position. 

Dissection after four days. Nothing appeared to indicate the seat 
of the bending except a small clot of blood in the centre of the shaft. 

Experiment 9. — Bent the leg of a chicken, six weeks old, in the 
same manner, and to the same degree, as in the other examples. It 
resumed its position spontaneously. 

Dissection after ten days. No evidence of injury of any kind ; the 
bone being sound and straight. 

These experiments were made in connection with others, which I 
shall take occasion hereafter to mention. They are selected, and con- 



74 BENDING, PARTIAL FRACTURES, AND FISSURES. 

stitute the whole number of those in which I did not feel the bone 
break or crack under my fingers. In every instance the bone sprung 
back immediately and spontaneously to its natural form. In no in- 
stance could I afterward discover any trace of lesion, or sign indicating 
the point at which the bone had been bent before dissection ; nor did 
dissection itself disclose anything but the most inconsiderable marks ; 
and that in but three examples. 

I infer, therefore, not forgetting the caution with which the conclu- 
sions from all such experiments ought to be. applied to similar acci- 
dents upon the human skeleton, that whenever the bones of healthy 
infants have been slightly bent and not broken, they will, probably, 
in most cases, unless prevented by causes foreign to the bones them- 
selves, spontaneously and immediately resume their position ; and 
that no sign will remain to indicate that a bending has occurred. The 
accident will not be recognized; and, as a farther inference, this 
bending does not belong to that class of cases of which I shall next 
speak. 

2. Bending without immediate and spontaneous restoration of the hone 
to its original form. — "Dethleef. believing that he had broken the two 
bones of the leg of a dog, found the fibula bent without a fracture. 
Similar results were obtained by Duhamel upon a lamb ; by Troja 
upon a pigeon ; and I have myself twice succeeded in bending the 
fibula while breaking the tibia. The possibility of simple curvature 
is then not contestable" (the writer means to say that the possibility 
of a simple curvature remaining permanently bent, is not contestable), 
"but we must observe that they have never been obtained except 
upon young animals, and that they have been unable to maintain 
themselves permanently except through the aid of a fracture and dis- 
placement of a neighboring bone ; and there is a wide difference 
between these and those pretended curvatures which some believe 
they have seen in man, in which the curved bone maintains itself, 
and resists perfect reduction until the fracture is complete." 1 

In this single paragraph Malgaigne seems to have given a fair sum- 
mary of the testimony upon this point. With the exception of these 
and a few other similar examples, some of which I think I have ob- 
served myself, where one of the bones of the forearm has been broken 
and the other bent, I know of no well-attested cases of a permanent 
bending ; using the term bending in a sense distinguished from a par- 
tial fracture. 

If, in numerous cases mentioned by surgical writers, there has seemed 
to be probable evidence that the permanent bending was unaccompa- 
nied with fracture, there has always been wanting, so far as I know, 
the positive evidence of dissection. The example of partial fracture 
mentioned by Fergusson, and represented by a drawing, is described 
as having also, "toward the lower extremity, a slight indentation and 
curve." 2 This was the radius of a child; but how long the child 
survived the accident, and what was the condition of the ulna we 

1 Traite des Frac, etc., par L. F. Malgaigne, torn. i. p. 48. 

2 Practical Surgery, by William Fergusson, 4th Am. ed., p. 208. 



BENDING OF THE LONG BONES. 



75 



Fig. 21. 




Case mentioned 
by Fergusson. 



are not informed. The observations made by Jurine, of Geneva, in 
Switzerland, 1 by Barton 2 and Norris, 3 of Philadelphia, all fail to fur- 
nish any such conclusive evidence of the correctness 
of their own views. ISTorris says that " Thierry, of 
Bordeaux, Martin, and Chevalier, had all met with 
and published cases of this kiud prior to the appear- 
ance of Jurine's paper (in 1810), the former of whom 
asserts that Haller, in experimenting upon the subject, 
had been able satisfactorily to produce the same acci- 
dent in young animals." For myself, I cannot say 
how much confidence we ought to place in these 
assertions of Thierry, Martin, and Chevalier, having 
never seen the papers referred to ; but since Dr. Nor- 
ris has neglected to inform us whether any dissections 
were ever made, we shall not be expected to regard 
their testimony as conclusive. 

With the qualifications now made, Gibson was more 
nearly right when he said, " Dupuytren and Dr. John 
Rhea Barton have each furnished accounts of bent bones. 
There are no such injuries, however, in my opinion ; 
such cases being, in reality, partial fractures, from 
which deformities result upon the same principle that a piece of tough 
wood, like oak or hickory, if broken half through, may be inclined to 
one side and shortened, although still held together by interlocking 
of fibres. Many specimens in my cabinet, and in the Wistar Museum, 
attest the accuracy of this assertion." 4 

In my own experiments upon the chicken, the bones uniformly 
resumed their original position as soon as the restraining force was 
removed, unless a fracture occurred, and this notwithstanding the 
bones were bent quite abruptly and to an angle of twenty-five de- 
grees. Certainly, if the bones of children may be bent during life and 
be made to retain this position without a fracture, then the same thing 
might be done upon the bones of children recently dead, and by suc- 
cessful experiments, this long agitated question might be easily and 
forever put to rest. 

It will be understood that our observations are confined to the long 
bones. That the flat bones, and especially the bones of the cranium, 
in childhood, may be indented by blows, 'and remain in this condition, 
is undeniable. Scultetus says he had seen " the skull pressed down 
in children, without a fracture, so that those who touch or look upon 
it can perceive a small pit," 5 and it has been mentioned by many wri- 
ters since, and perhaps before his day. I have myself published two 
examples of it in the second volume of the Buffalo Medical Journal? 



Journ. de Corvisart et Boyer, torn. xx. p. 278, etc. 

Phila. Med. Recorder, 1821. 

Phila. Med. Journ., vol. xxix. p. 233, 1842. 

Institutes and Practice of Surgery, by Wm. Gibson, Phila., 1841, vol. i. p. 254. 

The Chirurgeon's Storehouse, by Johannes Scultetus, 1674, p. 126. 

Op. cit., p. 347, 1846, Cases 1 and 2. 



76 



2. Partial Fracture of the Long Bones. 



1. Partial Fracture with immediate and spontaneous restoration of the 
hone to its original form. — No writer seems to have given any special 
attention to the form of fracture now under consideration, although its 
existence appears to have been occasionally recognized. In the case 
reported by Camper, in 1765, of a partial fracture of the tibia, the 
bone had regained its natural form, but whether immediately after 
the accident occurred, or at a later period, I am not able to learn. 1 
Jurine, Gulliver, and others, have noticed a gradual straightening of 
the bone after a partial fracture, so that its complete restoration has 
been accomplished after several weeks or months; but this, although 
partly due to the same cause which produces occasionally an immediate 
restoration, namely, its elasticity, is in part also due to other causes, 
and will be more properly considered under the next division of par- 
tial fractures. 

Says Malgaigne : " Finally, at other times the fracture takes place 
without opening and without curvature ; the only sign which one can 
recognize is a yielding of the bone under the pressure of the finger, at 
the point of fracture ; yet upon the living subject, we may see the 
same symptom pertain to complete and simple fractures without dis- 
placement." 2 

Blandin has described the accident a little more distinctly: "In 
some cases of fracture of the clavicle occurring about the middle of 
the bone in young subjects, displacement of the fragments does not 
immediately take place, thus giving rise to a risk of an error in 
diagnosis, by which the ultimate probability of a cure is diminished. 
A lad seventeen years of age, was recently admitted into the Hotel 
Dieu, under the care of M. Blandin, having, a few days previously, 
fallen upon one of his comrades while playing with him, when he 
instantly experienced pain and a cracking sensation about the middle 
of the left clavicle, where there soon formed a tumor, which increasing, 
induced him to enter the hospital. On examination, the swelling was 
found to occupy the middle of the clavicle ; it was about as large as 
half a hen's egg, ovoid in shape, well circumscribed, colorless, and 
hard, but sensible to pressure. There was not any deformity of the 
shoulder, nor any abnormal modification of the axis of the bone, to 
indicate the existence of a fracture ; and although the different move- 
ments of the arm caused pain in the shoulder, yet they could be made 
without much difficulty. 

" The symptoms in this case would lead to the belief that it was a 
case of simple periostitis, caused by external violence ; but M. Blandin 
at once decided that there existed a fracture of the bone, having seen 
a similar case previously at the hospital Beaujon, where the tumor 
was treated as traumatic periostitis, the patient merely carrying his 
arm in a sling, until, by a sudden movement of the limb, displacement 
of the fragments was produced, and clearly demonstrated the existence 

1 Essays and Obs. Phys. and Lit. of Soc. of Edinburgh, vol. iii. p. 537. 

2 Op. cit., torn i. p. 50. 



PAETIAL FRACTURE OF THE LONG BONES. 77 

of a fracture. A second case occurring soon afterward, M. Blandin 
profited by the experience gained from the preceding, and by moving 
the fragments of the broken clavicle on each other, obtained motion 
and crepitus. Still these indications were not so clear, that M. Mar- 
jolin could diagnosticate a fracture ; he was of opinion that the case 
was one of exostosis, probably syphilitic, and the crepitus, he believed, 
depended on an erosion of the osseous surface. In consequence, the 
patient was left to himself, until a movement of the arm gave proof of 
the fracture by the displacement of the broken portions of the bones. 

"Two other cases occurring in young subjects have been admitted 
since into the Hotel Dieu, under the care of M. Blandin, one of whom 
was purposely left without surgical assistance, while Desault's bandage 
was applied to the other. The former soon showed evidence of con- 
secutive displacement; the latter was cured without any deformity 
following. 

"The surgeon may diagnose a fracture, without displacement of the 
middle portion of the clavicle, when a circumscribed tumor forms in 
that part of young subjects, consecutive on a fall on the shoulder, and 
motion of the fragments, with crepitus, can be detected, there not 
being any syphilitic taint in the constitution." 1 

Prof. Green, of Geneva Med. Col., N. Y., has furnished me the fol- 
lowing account of a case which came under his observation. 

"December 21, 1847, I was called to dress what was considered to 
be a fractured clavicle, of George Stone, a lad eight years of age. One 
of his playmates had tripped him in such a manner that he fell on 
his side, striking on the extremity of the left shoulder. I found that 
he was unable to raise the hand to the head. On examination I 
discovered on the posterior edge of the clavicle, at the inner extremity 
of the external curvature, a point which was swollen, tender, and 
painful. The anterior edge of the clavicle was continuous, and there 
was neither crepitus nor displacement. Considering the age of the 
patient, and the appearance of the parts, I diagnosticated bending of 
the clavicle forward, with a splitting out of the posterior edge, and that 
the bone, by its elasticity, had resumed it ordinary direction. In 
order to be safe, however, I dressed the shoulder as for actual fracture 
of the clavicle, lest the fracture might have extended nearly through 
the bone, and there be subsequent displacement. The swelling subsided 
in four or five days, and as all seemed secure, I removed the dressings, 
and heard no more of the matter until the 11th of May, ult., when I 
was called to see the patient again, and found that he had met, the day 
before, with precisely the same accident, at the old point, and by the 
same cause, being tripped down by a playmate. This time the swell- 
ing and other symptoms of inflammation, were greater than before. 
The anterior edge of the clavicle was entirely continuous, but he could 
not raise the arm. I merely directed him to keep to his bed until the 
swelling and inflammation should in a measure subside. In three or 

• Am. Journ. Med. Sci., vol. xxxi. p. 473, from Journ. de Med. et Chirurg. Prat., 
July, 1842. 



78 

four days he was about. The callus left is not large, still it -is quite 
evident." 

The following examples which have come under my own observation, 
will illustrate more completely their usual history and symptoms : — 

A. B., aged three years, fell from the sofa upon the floor, striking, 
it is thought, on her right shoulder. Two days after this, she fell 
again, and then, for the first time, Mr. B. noticed the deformity. She 
was brought to me three days after the second fall. There existed 
then a round, smooth projection at the outer end of the middle third 
of the clavicle. It felt hard, like bone. The line of the clavicle was 
not changed. I advised a handkerchief sling, simply to steady and 
support the arm. Seven months after the accident, she fell sick and 
died. The projection continued at the time of death, only slightly 
diminished. 

H. S., aged six years, was thrown from a horse, partially breaking 
his left clavicle, near its middle. Dr. Sprague, of Buffalo, was em- 
ployed. The projection in front was for several days very apparent, 
and was examined by myself at Dr. Sprague's request. The bone did 
not seem to be out of line. Five years after the accident, I examined 
the lad, and could not find any trace of the original injury. 

September 25, 1855. Mrs. T. C. brought to me her infant child, 
then but two weeks old. Upon the left clavicle, at a point a little 
nearer the acromion process than the sternum, was an oblong swelling, 
three-quarters of an inch in length, smooth and hard like callus ; the 
skin was not reddened, nor tender. There was no motion or crepitus, 
and the line of the axis of the bone was perfect.. The mother, who 
had been put to bed by a midwife, thinks the injury occurred in the 
act of birth, although she did not notice the swelling until a week 
after. 

October 20. Nearly one month later, I found no change in the con- 
dition of the bone ; the hard lump remained, but it was still entirely 
free from tenderness. I have not seen the child since. 

An infant boy, three years old, fell, August 12, 1857, from the hands 
of the nurse. The child cried, but the point of injury was not de- 
tected until the third or fourth day, although the mother examined the 
shoulders and neck carefully at the time. She is quite certain that if 
any swelling or discoloration had been present she would have seen it 
then, or on the subsequent days, while washing and dressing the child. 
When first seen it was very distinct, but not so large as at present. 

August 19. The child was brought to me. A little to the sternal 
side of the middle of the right clavicle there was an oblong node-like 
swelling, of the size of the half of a pigeon's egg, hard, smooth, and 
feeling like bone ; there was no discoloration or swelling of the integu- 
ments ; no crepitus or motion ; the line of the clavicle seemed nearly 
or quite unchanged. 

I have not noticed this variety of accident in any other bone except 
the clavicle, yet it is not improbable that it happens occasionally, and 
perhaps quite as often, in other long bones, but that its existence is 
not elsewhere so easily recognized. 

Of one hundred and five iractures of the clavicle, recorded by me 



PAETIAL FRACTURE OF THE LONG BOXES. 79 

twenty-two were partial fractures ; and of these six were spontaneously 
and immediately restored to their natural axis. 

In explanation of the fact that hospital surgeons have not observed 
so large a proportion of partial fractures of the clavicle, it must be 
stated that nearly all these cases of partial fracture were drawn from 
private practice. Accidents of this class may be often met with in 
dispensaries, but they are seldom found in hospitals. 

Experiment. — In fourteen experiments upon the bones of chickens, 
a partial fracture, with immediate and spontaneous restoration, has 
occurred but once. In nine of these cases the bones were only bent, 
and in five they were partially broken ; an immediate restoration has 
occurred, therefore, in one case out of five of partial fracture ; while 
in my reported examples of partial fracture of the clavicle it has been 
noticed about once in every three or four cases. The following is the 
experiment to which I have referred : — 

I produced a partial fracture of the tibia in a chicken six weeks old. 
The fracture was near the middle of the bone. I felt it break under 
my ringer ; but on removing the pressure, it immediately and spon- 
taneously resumed the straight position. 

I dissected the limb on the tenth day. The line of the axis of the 
bone was perfect ; but on the fractured side was a node-like enlarge- 
ment, sufficient to be distinctly felt and seen before the soft parts were 
removed. 

Pathology. — In no case, except in my single experiment upon the 
bone of a chicken, has the actual condition been determined by dis- 
section, and if any question has existed heretofore as to the possibility 
of an immediate and spontaneous restoration after a partial fracture, 
this experiment ought to decide it in the affirmative ; but then the first 
nine experiments already quoted have shown that a mere bending with 
immediate restoration leaves no such traces or signs as have been de- 
scribed as following these accidents. We have, therefore, the negative 
argument that, since a bending with restoration leaves no signs, these 
examples reported by myself and others as having occurred, and as 
having been followed by a node-like swelling, etc., must have been 
partial fractures. Moreover, in one of the cases of immediate resto- 
ration reported by Blandin, there was a feeble crepitus; and in 
another, the subsequent displacement proved the correctness of his 
diagnosis. 

We conclude, then, that these are examples of partial fracture, but 
that the number of bony fibres which have given way are too incon- 
siderable, as compared with those not broken, to affect materially the 
elasticity of the bone. 

Diagnosis. — The diagnosis will depend somewhat upon the history 
of the accident as well as upon the present symptoms. In no instance, 
where I could ascertain the cause, have I known an incomplete frac- 
ture of this variety produced by any other than an indirect blow ; and 
where the clavicle has been the seat of the curvature the counter-blow 
has been received upon the end of the shoulder. This fact possesses, 
therefore, equal significance in its relation to either of the varieties of 
partial fracture : but in the case of a partial fracture with a permanent 



80 BENDING, PAETIAL FEACTUEES, AND FISSUEES. 

curvature, the diagnosis would be complete without the history, while 
in this case it might not be, and a knowledge of the manner in which 
the accident occurred would, therefore, be of great importance. 

The signs, then, after a knowledge of the fact that a blow has been 
received upon the shoulder, are a node-like swelling upon the anterior 
or upper face of the clavicle, generally in its middle third, this swell- 
ing being hard, smooth, oblong ; the skin only slightly or not at all 
swollen or tender, and in no way discolored, as it would have been 
had the swelling upon the bone been the result of a direct blow, and 
the line of the axis of the bone unchanged. I have never detected 
motion or crepitus at the point of injury, yet we have seen that Blan- 
din was able to detect both in one instance ; nor has it ever occurred 
to me to see the swelling upon the bone until two or three days after 
the injury was received. We are not likely, therefore, to recognize 
this accident immediately after its occurrence. 

Treatment. — In the case of the clavicle, neither bandages, slings, 
compresses, nor'lotions can be of much service. Yet no harm can 
arise from employing a simple sling and roller to confine the arm ; 
and it is always proper to enjoin some degree of care in using the arm 
of the injured side. The consolidation will be speedily accomplished, 
and after a time the ensheathing callus will wholly disappear. 

If a similar accident should occur in any other of the long bones, 
as retentive and precautionary means, splints ought to be applied, at 
least for a few days. 

2. Partial Fracture without immediate and spontaneous restoration of 
the bone to its natural form. — The causes of this accident are the same 
with those which produce simple bending, or partial fracture with im- 
mediate and spontaneous restoration, from which latter they differ 
probably in the greater extent of the bony lesion. Perhaps, also, they 
differ sometimes in the peculiar form and degree of the denticulation 
at the seat of the fracture ; in consequence of which an antagonism of 
the fibres takes place, preventing a restoration of the bone to its 
original form. 

They constitute a large majority of those examples of partial frac- 
ture which come under our observation in the various long bones. In 
one hundred and five fractures of the clavicle, it has been observed by 
me sixteen times. In two hundred and nine fractures of the radius 
and ulna, it has occurred twelve times. 

It has not happened to me to meet with this fracture in any other 
bone ; but examples have been mentioned as having occurred in the 
humerus, ribs, femur, tibia, and fibula. 

Very few surgeons have spoken of partial fractures in the clavicle, 
while Jurine, Syme, Liston, Miller, Norris, and many others, have 
declared that it is much more frequent in the bones of the forearm 
than elsewhere. This does not agree with my experience, according 
to which it occurs oftener in the clavicle than in the forearm ; a 
discrepancy which I cannot very well explain, except by supposing 
that, in the case of the clavicle, the accident has either been over- 
looked entirely or misapprehended. Blandin, who, we have seen, has 



PARTIAL FRACTURE OF THE LONG BONES. 



81 



reported five cases of partial fracture of the clavicle with immediate 
restoration, states distinctly that in two of these cases distinguished 



Fig. 22. 



Fig. 23. 




Partial fracture -with- 
out restoration of the 
bone to its natural form. 



IlimmiiillUi'" 
Partial fracture of the clavicle without spontaneous restoration. From 
nature ; taken three weeks after the accident. 

surgeons of Hopital Beaujon and Hotel Dieu failed 
to recognize it. 

Says Turner: "The next I shall descend to is 
that of the clavicle or collar-bone, which I have 
found the most frequently overlooked, I think, of 
any other, till it has been sometimes too late to 
remedy, especially among the children of poor peo- 
ple ; for, though they find these little ones to wince, 
scream, or cry, upon the taking off or putting on 
their clothes, yet, seeing that they suffer the handling of their wrists 
and arms, though it be with pain, they suspect only some sprain or 
wrench, that will go away of itself, without regarding anything 
further or looking out for help ; whereas, this fracture discovers 
itself as easily as most others. For not only the eye, in examining 
or taking a view of the part, may plainly perceive a bunching out or 
protuberance of the bones when the neck is bared for that purpose, 
with a sinking down in the middle or on one side thereof, which will 
be still more obvious on comparing it with its fellow on the other 
side : but when it is more obscure, and the bone, as it were, cracked 
only — a semi-fracture, as we say — yet, by pressing hard upon the part, 
from one extremity to the other, you will find your patient crying 
out when you come upon the place ; and by your fingers, so examining, 
sometimes perceive a sinking farther down, with a crackling of the 
bone itself." 1 

Erichsen, who regards all of these cases as mere bendings of the 
bones, remarks that it "most commonly occurs in the long bones, 
especially the clavicle, the radius, and the femur." 2 He says, more- 



1 Art of Surgery, by Daniel Turner, London, 1742, vol. ii. p. 255. 

2 Science and Art of Surgery, Phila. ed., 1854, p. 180. 



82 



BENDING, PAETIAL FKACTUKES, AND FISSURES. 



over, "Fracture of the clavicle in infants not unfrequently occurs, and 
is apt to be overlooked. The child cries and suffers pain whenever 
the arm is moved. On examination, an irregularity, with some 
protuberance, will be felt about the centre of the bone." 1 The reader 
will not fail to recognize, in these symptoms the incomplete fracture 
of which we are now speaking, although Erichsen evidently believes 
them to be examples of complete fracture. 

In addition to this testimony as to the frequency of these fractures 
in the clavicle, I will, only mention that Johnson, in his review of 
Markham's Observations on the Surgical Practice of Paris, says that 
" many surgeons have noticed the incomplete fracture of the clavicle, 
as of other bones, which takes place in the young." 2 

Pathology. — The following experiments will assist in the elucidation 
of this point of our subject: — 

Experiment 1. — I bent the leg of a chicken five weeks old. It 
cracked under my fingers, and remained bent. Having waited a few 
seconds, and finding that it was not restored to position, I pressed upon 
it and made it straight. The chicken walked off without any limp. 
On the fourth day, before dissection, the bone looked as if it was 
still bent ; but on removing the soft parts, the line 
Fig. 24. f ^q ax i s f the bone was found to be straight. The 

areolar tissue under the skin was infiltrated with 
lymph, which was most abundant near the fracture, 
and gradually diminished towards each extremity of 
the limb. This effusion was confined almost entirely 
to the front of the limb, or to that side which had 
been broken, and constituted the greater part of the 
enlargement which I had noticed before the dissec- 
tion was commenced, and which then felt like bone. 

On the front of the bone, also, underneath the pe- 
riosteum, there was a loose, honeycomb deposit of 
ensheathing callus, about one line in thickness, and 
extending upward and downward about half an inch. 
This callus surrounded the bone in three-fourths of 
its circumference; but there was no callus on its 
posterior surface. It was also deficient exactly along 
the line of fracture, in front and on the sides, in con- 
sequence of which an oblique groove remained, indi- 
cating the seat of the fracture. 

Experiment 2. — I produced a partial fracture at the 
same point, in a chicken five weeks old. The bone 
was felt to crack, and, as it would not straighten spon- 
taneously, I immediately bent it back to its place. 

On the eighth day I dissected the limb. The ap- 
pearances, before and after dissection, were the same 
as in Experiment 1. No ensheathing callus on the 
posterior surface. The furrow over the line of fracture 



Partial fracture 
after union is con- 
summated. 



1 Science and Art of Surgery, Phila. ed., 1854, p. 205. 

2 Loud. Med.-Chir. Rev., vol. xxxiv. p. 474, 1841. 



PAETIAL FRACTURE OF THE LONG BONES. 83 

w&s not quite so deep as in Experiment 1. On opening into the centre 
of the shaft I found the canal Dearly filled with bony matter opposite 
the fracture, and the broken ends were completely united. 

Experiment 3. — This was made upon the opposite leg of the same 
chicken, and with the same results. 

Experiment 4. — Same as Experiment 1, except that I supposed at 
first the bone was broken completely off The dissection showed, 
however, that such was not the fact. The posterior wall was a little 
thickened, but the ensheathing callus was only in front and on the 
two sides. The medullary canal was closed with bone. 

So early as the year 1673, a dissection made by Glaser demon- 
strated incontestably the existence of partial fractures in the shaft, 
and in, the direction of the diameter of long bones. 1 Camper, in 
1765, again described a specimen which he had seen; 2 and Bonn, 
in 1783, added a third positive observation. 3 

M. Grimele is, therefore, in error when he ascribes to Campaignac 
the credit of having first proven by dissection their existence, in a 
paper communicated to the Academy of Medicine at Paris, in 1826. 
Campaignac, however, seems to have been the first who described 
very particularly the condition of this fracture. He has recorded the 
history and dissection of two cases, one of which occurred in the 
fibula, and one in the tibia. The first of these cases was a girl twelve 
years old, who survived the accident just eight weeks. The fracture 
had occurred near the middle of the bone, and upon the anterior and 
internal side ; in which direction, resting against the tibia, the bone 
was found inclined. " The bony fibres had been broken at different 
lengths, almost exactly like what takes place in the branch of a tree 
which has been partially broken ; and, as we see sometimes in this 
latter case, the bundles of splintered bony fibres abutted upon them- 
selves, and did not take their places when we endeavored to restore 
them ; so the abnormal angle which the fibula represented could not 
be effaced, the ends of the divided fasciculi not restoring themselves 
to their respective places. This disposition might be especially seen 
toward the anterior part of the internal face, where a packet of fibres 
coming from below, was braced against the upper lip of the division, 
which it thus held open. This opening at first made me think that 
the fragments could not have been well consolidated ; but I assured 
myself that it was, and the fact was subsequently confirmed by the 
Academy of Medicine; all the points which were in contact were 
found intimately united." 4 

Diagnosis. — The diagnosis is not difficult. The distortion indicates 
sufficiently the existence of a fracture, while the complete absence of 
crepitus in nearly all cases, and of either overlapping or lateral dis- 
placement, must, generally, especially where the accident has occurred 
in a child, sufficiently indicate that the fracture is incomplete. It will 

1 Malgaigne, op. cit., p. 44, from Th. Boneti Sepulchretum, 1700, torn. iii. p. 424. 

2 Essays and Obs. Phys. and Lit. of Soc. of Edinburgh, 1771, vol. iii. p. 537. 

3 Malgaigne, op. cit., p. 44, from Descript. Thes. Ossiurn Morb. Hoviani, 1783. 

4 Des Fractures Incompletes et des Fractures Longitudinales des Os des Membres ; 
par J. A. J. Campaignac. Paris, 1829, pp. 9-10. 



84 BENDING, PARTIAL FRACTURES, AND FISSURES. 

assist the diagnosis also to notice that these accidents" are almost con- 
fined to the middle third of the long bones ; and they are produced 
usually by a bending of the bones, the forces operating upon the 
extremities, and not directly upon the point which is broken. 

In complete fractures, also, preternatural mobility is so constant a 
sign as to be regarded as diagnostic, while here there is almost always 
a great degree of immobility at the seat of fracture. The angle made 
by the projecting extremities is usually rather gentle and smooth ; 
at other times it is abrupt, indicating a greater amount of fracture, or 
that the outer fibres are broken more irregularly. The power of using 
the limb is generally sensibly impaired, but not completely lost. 

Treatment. — Jurine, Murat, Campaignac, Gulliver, Malgaigne, with 
some others, have noticed the fact that it is often difficult, and some- 
times quite impossible, to restore these bones to position; a cir- 
cumstance which they have justly ascribed to that condition of the 
fragments described by Campaignac. The broken extremities of the 
fasciculi become braced against each other, and effectually resist all 
efforts to straighten the bone; unless, indeed, so much force is used as 
to render the fracture complete : a result which, if it should chance to 
happen, need not occasion any alarm, since, while it enables us at once 
to restore the bone to line, does not much increase the danger of lateral 
displacement and overlapping. That the fracture has become com- 
plete we may know by a sudden sensation of cracking, by the increased 
mobility, and by the crepitus which is now easily developed. 

Bat we need not, on the other hand, be over anxious to straighten 
the bone completely, since experience has shown that after the lapse 
of a few weeks or months the natural form is usually restored spon- 
taneously. I am not now speaking of those cases in which the resto- 
ration occurs immediately, where it is probable that the splintered 
fibres offer no resistance to the restoration ; but only of those in which 
the bone straightens so gradually as to induce a belief that the broken 
ends are the cause of the resistance. To this variety of accident belong 
cases one, five, six, seven, and eight, published in my Eeport on De- 
formities after Fractures; 1 in one of which the natural axis was resumed 
in less than four weeks. In a case mentioned by Grulliver, it required 
about the same time to render the bones of the forearm perfectly 
straight; and in one case mentioned by Jurine, at the end of six 
months it was ''difficult to say which arm had been broken, and at 
the end of one year it was impossible." 

Jurine attributes this restoration to " muscular action, or more 
especially to the reaction of the compressed bony plates ;" but while 
it is easy to understand how the reaction of the compressed fibres 
may accomplish the gradual restoration, I am unable to understand in 
what manner muscular action contributes to this result, since most of 
the muscles attached to the long bones operate so much more ener- 
getically in the direction of their axes than in the direction of their 
diameters. Indeed we have often seen these bones bent after com- 
plete fractures, and before the union was consummated, by muscular 
action alone. 

1 Trans. Am. Med. Assoc, vol. viii., 1855, pp. 392-5. 



FISSUKES. 85 

I repeat, then, that the gradual restoration of these bones is due to 
the same circumstance which produces at other times an immediate 
restoration, namely, the elasticity of the unbroken fibres, but which 
elasticity, in this latter instance, is, for a time, effectually resisted bv 
the bracing of the broken fibres. At length, however, in consequence 
of the gradual absorption of the broken ends, this resistance is removed, 
and the bone becomes straight. If this absorption refuses to take 
place, and the fibres continue pressed forcibly against each other, as 
in the case described by Campaignac, then the bone remains perma- 
nently bent. 

Having straightened the bone as far as is practicable, it only remains 
to secure the fragments in place by suitable bandages or splints. If 
the restoration is incomplete, these means may assist the efforts of 
nature in accomplishing a gradual restoration. 

It is scarcely necessary to say that extension and counter-extension 
avail nothing in partial fractures. 



§ 3. Fissures. 

These constitute the second principal form of incomplete fractures, 
or those in which the fracture is accompanied with no appreciable 
bending, which occur almost exclusively in inflexible bones, such as 
the compact bones of adults, and more often in the direction of their 
axes than of their diameters. They are complete so far as they extend, 
but they do not completely sever the bone so as to form two distinct 
fragments. They have been most frequently observed in the flat 
bones, such as the bones of the skull, and in the upper bones of the 
face ; occasionally in the long bones, both in their diaphyses and epi- 
physes, and rarely in the short bones. 

M. Gariel has reported, in the Bulletins de la Societe Anat., for 1835, 
a case of fissure of the inferior maxilla, occurring in a lad sixteen or 
eighteen years old. Palletta found a fissure extending partly through 
the third dorsal vertebra, in a man who had fallen upon his back 
eleven days before ; and M. Lisfranc has mentioned a remarkable case 
of fissure and partial fracture, with bending of five ribs in the same 
person. 1 Malgaigne believes that he has seen one example of this 
variety of incomplete fracture of the scapula, occurring through a 
portion of the infra-spinous region. I have myself elsewhere recorded 
another, as having been found in the skeleton of Nimham, an Oneida 
Indian, who was a great fighter, and who died when about forty-five 
years old, in consequence of severe injuries received in a street brawl ; 
but his death did not occur until four or five months after the receipt 
of the injuries. 

In addition to this fracture of the right scapula, five of his ribs 
were broken, and both legs, all of which, except the scapula, had united 
completely by intermediate and ensheathing callus. 

The scapula was broken nearly transversely, the fracture com- 

1 Des Fract. Incomplet. et des Fissures, par J. A. J. Campaignac, 1829, p. 20. 



86 

mencing upon the posterior margin at a point abont three-quarters of 
an inch below the spine, and extending across the body of the bone 
one inch and three-quarters, in a direction inclining a little upwards, 
being irregularly denticulate and without comminution. The frag- 
ments were in exact opposition, and, throughout most of their extent, 
in immediate contact. They were, however, not consolidated at any 
point, but upon either side of the fissure there was a ridge of en- 
sheathing callus, of from one to three or four lines in breadth, and of 
half a line or less in thickness along the broken margin, from which 
point it subsided gradually to the level of the sound bone. The same 
was observed upon the inner as well as upon the outer surface of the 
scapula. This callus had assumed the character of complete bone, 
but it was more light and spongy than the natural tissue, and the 
outer surface had not yet become lamellated. Its blood-canals and 
bone-cells opened everywhere upon the surface. 

Directly over the fracture, and between its opposing edges, no callus 
existed, but as the bone had lain some time in the earth before it was 
exhumed, it is probable that a less completely organized intermediate 
callus had occupied this space, and that, owing to the less proportion 
of earthy matter which it contained, it had become decomposed and 
had been removed. 

M. Yoillemier found the head of the humerus penetrated by two or 
three fissures; 1 and M. Campaignac has reported the case of a lad ten 
or twelve years old, who was compelled to submit to amputation of 
his arm at the shoulder-joint, in consequence of a severe injury, in 
which the humerus was found fissured from the insertion of the del- 
toid to near the condyles, extending through the entire thickness of 
the bone, and the edges of the fissures so much separated toward its 
lower extremity as to admit the blade of a knife. 2 Chaussier has 
related a case in which a criminal, who died soon after having sub- 
mitted to the torture, was found to have a nearly longitudinal fissure 
of the radius in its upper fourth, and which penetrated half way 
through the thickness of the bone. 3 Gulliver saw a fissure in the 
pelvis of an infant. 4 Malgaigne has seen two specimens of this frac- 
ture in the iliac bones, both of which belonged, as he thinks, to adults ; 
in one, the fissure was limited to the internal table ; 5 and in the case 
of the lad reported by Gariel, as having a fissure of the inferior 
maxilla, there was also found a fissure of the left ilium, but which 
was limited to the outer table. 6 

Mt J. Cloquet has mentioned a case of fissure of the shaft of the 
femur passing through the condyles and extending upward to near 
the middle of the bone. The fissure was produced by a bullet, which 
had completely traversed the bone from behind forward, a little above 
the condyles. 7 M. Malgaigne has also represented, in one of his plates, 

1 Malgaigne, op. cit., p. 35. 

2 Campaignac, Des Fract. Incomplet., &c, p. 24. 

3 Med. Legale, p. 447 et seq. * Gazette Med., 1835, p. 472. 

5 Op. cit., "p. 34. e Bulletins de la Soc. Anat., 1835, p. 24. 

" These du Concours de Pathol. Externe, 1831, pi. xii., fig. 7. Also, Des Frac, etc., 
par Campaignac, 1829, p. 19. 



FISSURES. 87 

a fissure of the femur extending along the front of the bone, some- 
what irregularly, from a point a little below the trochanter minor to 
near the conchies. 1 The bone was presented to the Museum of Val- 
de- Grace, by M. Fleury ; but it is to be regretted that we have no 
farther account of this remarkable specimen. Certainly, in the com- 
plete absence of any farther history of the case, one might be justified 
in expressing a doubt whether it was not a fissure occasioned by the 
contraction consequent upon exposure and drying after death. 

The following account of a fissure of the neck of the femur, of the 
same character with those which now occupy our attention, is copied 
from, the proceedings of the " Boston Soc. for Med. Improvement," at 
its regular meeting in September, 1856 : — 

" Partial Fracture of the Neck of the Femur in a man set. 44 years. 
Specimen shown by Dr. Jackson. — The fracture, which appears as a 
mere crack in the bone, commences anteriorly just above, but very 
near to, the insertion of the capsular ligament, runs along this inser- 
tion for about an inch, and then extends directly upward to the mar- 
gin of the head of the bone. From this last point it crosses the upper 
surface of the neck almost in a straight line, and at a little distance 
from the margin of the head, but afterward approaches very closely 
to this margin posteriorly; it then turns downward and obliquely 
forward, and stops at a point about half way between the small tro- 
chanter and the head of the femur, and two thirds of an inch or more 
anteriorly to the line of this trochanter. The fracture then involves 
about three-fourths of the neck of the bone ; the inner-anterior portion 
only being spared. There is considerable motion between the neck 
and the shaft, and the fracture could, undoubtedly, be completed with- 
out the application of any extraordinary force. Dr. J. referred to 
other cases of partial fracture ; but a fracture of this sort, as occurring 
in this situation, and in a fully adult subject, he believed had never 
before been described. There was, also, in this case, a transverse frac- 
ture of the same femur midway, with a split extending upward nearly 
to the neck of the bone; and still further, a fracture of the spine. The 
patient, a laboring man, fell through two stories of a building and 
down upon a hard floor. On the same day he entered the Massachu- 
setts General Hospital, and on the 18th day from the time of the acci- 
dent he died. The femur is perfectly healthy in structure, and no 
changes are observable in the bone about the fracture." 2 

Whatever doubts may have been thrown upon the possibility of this 
accident, as applied to the neck of the femur, by the ingenious argu- 
ments of Robert Smith, of Dublin, 3 the question is now at least deter- 
mined by an incontestable fact. Dr. Smith had rendered it quite pro- 
bable that both Colles and Adams were mistaken, and that the cases 
described by them were examples of impacted fracture, and not of 
partial fracture ; but, in arguing the improbability of its occurrence, 

* Op. cit.,p. 37, pi. 1, fig. 1. 

2 Best. Med. and Surg. Joura., vol. lv. p. 351. See, also, Amer. Journ. Med. Sci. 
for 1857, p. 306 ; with engraving. 

3 Treatise on Fractures in the Vicinity of Joints, etc., by Robert Wm. Smith, 
Dublin, 1854, p. 44 et seq. 



PAKTIAL 

from the infrequency of fractures of the neck of the femur in early 
life, he overlooked the fact that there were two forms of incomplete 
fractures, and that it was only the " green stick" fracture which be- 
longed mostly to childhood ; " fissures" being found most often in the 
bones of adults. Indeed, I think the example recorded by Tournel 
in the Archives de Medecine, had already, so early as the year 1837, 
established the possibility of a "fissure" in the neck of the femur; al- 
though by Malgaigne this case has been mentioned as an example of 
that other variety of partial fractures which is almost peculiar to 
childhood, and in which the bones yield quite as much by bending as 
by breaking. But the man was eighty-five years old, and, having 
died three months and a half after the accident, a long crevice was 
found, extending nearly through the neck of the femur, partly within 
and partly without the capsule. 

I have seen, in Dr. Mutter's valuable collection of bones at Phila- 
delphia, a specimen of fissure of the trochanter major, which, it is 
believed, occasioned the death of the patient by hemorrhage. 

Gulliver says there is an example of a fissure in a patella belonging 
to the museum of the Edinburgh College of Surgeons ; the fissure tra- 
versing its articular face only. 1 

The first example of a fissure of the tibia is recorded by Corn. Stal- 
part Yander-Wiel, in 1687; and indeed this is, according to Cam- 
paignac, the first exact observation of this species of fracture which 
our science possesses, although its existence had been recognized by 
the most ancient authors. A servant had been kicked by a horse, and 
after a time, pain continuing in the limb, his surgeon, Dufoix, suspected 
a fissure of the tibia, and having cut down to the bone, a cure was 
soon effected. 2 

In the Dupuytren Museum, at Paris, there are two tibias with linear 
fractures ; one without history, and the other presented by MM. Mar- 
jolin and Eullier, " and which had been broken by a ball." 3 In the 
example related by Campaignac, a woman, having leaped from a 
second-story window, died immediately, and upon examination she 
was found to have three fissures in the upper portion of the left tibia, 
one only of which entered the articulation. 4 

The soldier spoken of by Became, having been struck upon the 
middle of the tibia, continued to march for some distance ; but serious 
complications ensuing, he finally died. A fissure was found, after 
death, near the middle of the shaft of the tibia. 5 

Leveille relates that an Austrian soldier had his leg penetrated by 
a ball at the battle of Marengo ; from thence he marched several miles 
and then was transported to Pavia. Although the wound at first 
seemed very simple, graver symptoms soon followed, and it became 
necessary to amputate the thigh. Dissection showed that the ball had 
occasioned several oblique and longitudinal fissures, which extended 
nearly the whole length of the shaft of the bone. 6 

1 Malgaigne, op. cit., page 35. 2 Campaignac, op. cit., p. 17. 

3 Malgaigne, op. cit., p. 36. 4 Campaignac, op. cit., p. 21. 

6 Abrege des Maladies qui attaquent la Substance des Os. Toulouse, 1775, p. 134. 
b Malgaigne, op. cit.. p. 39. See, also, Chapter ou Gunshot Fractures in this volume. 



FISSUEES. • 89 

Many similar examples of fissure from "perforating" gunshot 
wounds of the bone have been observed during the late war in this 
country ; but as these examples belong peculiarly to military surgery, 
they will be discussed more at' length in the chapter on gunshot frac- 
tures. 

Duverney saw a priest who had fallen and bruised the middle of his 
left leg ; the swelling and pain consequent upon which were subdued 
after a few days. The patient believed himself cured, and acted ac- 
cordingly. Suddenly, in the night, he was seized with, an acute pain 
in the limb ; and on cutting down to the bone, a bloody serum escaped 
from between it and the periosteum, and the bone was discovered to 
be fissured longitudinally. Subsequently the tibia was trephined, but 
the fissure did not reach the marrow. He recovered completely in 
less than two months. 

The same writer mentions another case in which a soldier received 
the kick of a horse in the middle of his left leg which was followed 
immediately by great pain, and subsequently by much inflammation, 
and even gangrene of the skin. The wound, however, cicatrized 
kindly, but after three months he was seized suddenly with a severe 
pain in the limb ; and, after the trial of many remedies, resort was 
finally had to the knife, when the tibia was seen to be discolored, and 
cracked longitudinally. On the following day the bone was opened 
over the course of the fissure with a chisel and mallet, and the patient 
was at once relieved by the escape of a yellowish and very offensive 
matter. At the next dressing, the bone was opened more freely by 
several applications of the trephine, and an abscess was exposed in 
the centre of the bone. The patient finally recovered after about four 
months. 1 M. Campaignac saw, also, at the hospital La Charite, the 
tibia of a woman, set. 38 years, upon which were found four fissures ; 
the report of which case is accompanied with a wood-cut illustration: 2 

Fissures may occur probably at all periods of life, but they are more 
frequently found in the bones of adults. Campaignac, however, men- 
tions a fissure of the humerus in a child ten or twelve years old, and 
Gulliver has seen a fissure in the pelvis of an infant. 

Etiology. — They may be occasioned by most of those causes which 
produce fractures in general, such as direct or indirect shocks; but 
they are occasioned much more often by direct blows, especially when 
infli-"?d upon bones imperfectly covered by soft parts, such as the 
tibia. Bullets, having violently struck or penetrated the bone, have 
frequently occasioned fissures. 

Their course may be parallel with the axis of the bone, oblique 
or transverse; they are often multiple; some merely enter the outer 
laminae, others open into the cellular tissue, and others still divide both 
surfaces of the bone through and through; and, according as they 
penetrate more or less deeply the bone, their lips will be found to be 
more or less separated. They frequently extend into the joint surfaces. 

Diagnosis. — The signs which indicate the existence of a fissure must, 
in a large majority of cases, be insufficient to determine fully the 

1 Malgaigne, op. cit., p. 39 et seq. 2 Campaignac, op. oit., pp. 21-22. 

7 



90 FRACTURES OF THE NOSE. 

diagnosis during the life of the patient. It is not probable that such 
fissures could ever be clearly made out by the touch alone, where the 
skin is not broken, since the pain, swelling, suppuration, etc., are only 
characteristic of inflammation of the bone or of its coverings, and 
might be equally present whether a fracture existed or not. In those 
rare cases only in which the flesh is torn off, and the surface of the 
bone is brought directly under the observation of the eye, will the 
diagnosis become certain. 

Treatment. — Fortunately, an error in judgment in this matter will 
not materially, if at all, prejudice the interests of the patient; since 
whatever may be the fact in other respects, if the bone, or its perios- 
teum, or its medullary membrane, is inflamed, and rest, with anti- 
phlogistics, does not accomplish its speedy resolution, incisions and 
perforations become inevitable, if we would give either safety or relief 
to the sufferer. Accordingly, in the inflammation and suppuration 
consequent upon these fractures, we have seen that it has been occa- 
sionally found necessary to lay open the soft tissues freely, and even 
to trephine the bone at one or more points. 

Fissures in Cartilage. — I have once met with a fissure in the thyroid 
cartilage, which constitutes, so far as I know, the only example upon 
record of a fissure in cartilage. 1 



CHAPTEE VIII. 

FKACTUKES OF THE NOSE. 
§ 1. Ossa Nasi. 

Of twenty -four cases of fracture of the ossa nasi recorded by me 
only fourteen were seen by a surgeon in time to afford relief. It 
seemed to me necessary, therefore, that the student should be in- 
structed how frequently the nature of this accident is overlooked 
by the friends, and even by the surgeon himself, to the end that he 
might be thus admonished of the necessity of always instituting, in 
such cases, careful and thorough examinations. In some of the cases 
recorded in my notes, where surgeons were called in time, and a de- 
formity remains, it is not improbable that the accident was not recog- 
nized. The rapidity with which swelling ensues after severe blows 
upon the nose, concealing at once the bones, and lifting the skin even 
above its natural level, explains these mistakes. The nose, also, is 
remarkably sensitive, and the patient is often exceedingly reluctant 
to submit to a thorough examination. It ought, however, not to be 
forgotten that the omission on the part of the surgeon to do his duty 

1 See Buffalo Med. Journ., vol xiii. Article entitled Fracture of the Thyroid Car- 
tilage. 



OSSA NASI. yi 

will not always be excused, even though the patient himself has pro- 
tested against his interference, especially where an organ so prominent, 
and so important to the harmony of the face, is the subject of his 
neglect or mal-adjustment; siuce the most trivial deviation from its 
original form or position, even to the extent of one or two lines, 
becomes a serious deformity. 

When the ossa nasi are struck with considerable force, from before 
and from above, a transverse fracture occurs usually within from three 
to six lines of their lower and free margins, and the fragments are 
simply displaced backwards, or if the blow is received partially upon 
one side, they are displaced more or less laterally. This is what will 
happen in a great majority of cases, as I have proven by examinations 
of the noses of those persons who have been the subjects of this acci- 
dent, both before and after death, by repeated experiments upon 
the recent subject. 

These fragments are generally loose and easily pressed back into 
place by. the use of a proper instrument. A silver female catheter, 
which we have seen recommended by surgeons, may answer well 
enough in a few instances, but it will more often fail. The diameter 
of the meatus at the point where the instrument must touch in order 
to make effective pressure upon the ossa nasi, is on the average not 
more than two lines, and when the membrane which lines it is injured, 
it becomes quickly swollen, and reduces the breadth of the channel to a 
line or less. Under these circumstances, any instrument of the size 
of a female catheter could only be made to reach and press against 
the nasal process of the superior maxilla, which is too firm and un- 
yielding to allow it to pass without the employment of unwarrantable 
force. In this way it happens that the operator is occasionally sur- 
prised to find how much resistance is opposed to his efforts to lift the 
bones, and after repeated unsuccessful attempts the case is not unfre- 
quentiy given over. If, however, he had used a smaller instrument, 
he would have found almost no resistance whatever. A straight steel 
director, or sound, or sometimes even a much smaller instrument, if 
possessing sufficient firmness, is more suitable than the catheter. For 
the same reason, also, one ought never to wrap the end of the instru- 
ment with a piece of cotton cloth as some have, I suspect, without 
much consideration, recommended. 

What I have said of the facility with which these bones may be 
replaced, when a proper instrument is employed, is true only when^ 
the treatment is adopted immediately, or at most within a few days 
after the accident. 

Boyer, Malgaigne, and others have noticed the fact that these frac- 
tures are repaired with great rapidity. Hippocrates thought the union 
was generally complete in six days; and in a case which has come 
under my own observation, the fragments were quite firmly united on 
the seventh day. 

Nor has Malgaigne, whose observations are always very accurate, 
overlooked the fact, also, that their repair is effected without the in- 
terposition of provisional callus, but, as it were, " par premiere inten 
Hon." My own observation confirms this statement. Among all the 



92 FRACTURES OF THE NOSE. 

specimens which I have seen in the various college and private col- 
lections illustrating fractures of the ossa nasi, and amounting in all to 
over forty, in no instance has there been detected, after a careful ex- 
amination, the slightest trace of provisional callus. 

I am not certain that it will always be found so easy to retain these 
loose fragments in place, as it is to replace them. The very swelling 
which takes place so promptly under the skin tends to depress the 
fragments, unsupported as they are by any counter force ; a tendency 
which, possibly, is in some instances increased by attempts on the 
part of the patient to clear his nostrils by snuffing and hawking. I 
have, in one instance, noticed very plainly a motion in the fragments 
when such efforts were made. How we are to remedy this I am not 
prepared to say. None of the plans which I have seen suggested 
possess, in my estimation, very much practical value. Few patients 
will consent to the introduction of pledgets of lint, or of stuffed bags, 
or, indeed, of anything else, sufficiently far up into the nostrils to 
answer any useful purpose. The membrane is too sensitive and too 
intolerant of irritants to enable us to have recourse generally to such 
methods. Then, too, it would require, on the part of the surgeon, 
more than ordinary tact to accomplish so nice and delicate an adjust- 
ment of the supports from below as these cases demand, where the 
slightest excess of pressure, or the least fault in the position of the 
compress must defeat the purpose of the operator. 

Yet, if one were disposed to make the attempt in certain cases 
where the comminution was very great, or where, for any other rea- 
son, the fragments would not remain in place, I think there could be 
no better plan than to push up in succession a number of small pledgets 
of patent lint, smeared with simple cerate, to each one of which there 
has been attached a separate string, so arranged as that their relative 
position may be recognized, and that they may at a suitable time be 
removed in the order of their introduction. 

The employment of canulas, as recommended by Boyer, B. Bell, 
•and others, allows of the nostrils being stuffed without interfering 
materially with the breathing ; a provision, however, which is quite 
unnecessary with a majority of persons, so long as there exists no 
impediment to the free admission of air through the fauces. 

With nicely adjusted compresses made of soft cotton or lint, and 
secured upon the outside of the nose with delicate strips of adhesive 
plaster or rollers, we shall be better able to prevent the fragments 
from becoming displaced outwards than by moulds of wax, of lead, or 
of gutta percha, under which it is impossible to see from hour to hour 
what is transpiring. 

The complicated apparatus devised by Dubois and recommended 
by Malgaigne, to lift the bones and retain them in place, seems to me 
indeed very ingenious, but destitute of a single practical advantage. 

A more considerable force than that which I have first supposed 
will break, generally, the ossa nasi transversely and a little above 
their middle, while, at the same time, the nasal processes of the supe- 
rior maxillary bones may suffer slightly. 

With neither of these accidents is the cribriform plate of the eth- 



OSSA NASI. 93 

moid likely to be broken or disturbed. Indeed, in numerous experi- 
ments made upon the recent subject, and in which the force of the 
blow was directed backwards and upwards, breaking and comminuting 
the nasal bones above and below their middle, with also the nasal 
processes of the superior maxillary bones, and the septum nasi, the 
cribriform plate of the ethmoid was, without an exception, uninjured. 
The exceeding tenuity and flexibility of the septum nasi at certain 
points prevents effectually the concussion from being communicated 
through it to the base of the brain. If, therefore, after these accidents, 
cerebral symptoms are occasionally present, as I have myself twice 
seen, 1 they must be due rather to the concussive effects of the blow 
upon the very summit of the nasal bones, where they rest immediately 
upon the nasal spine of the os frontis, or to some direct impression 
upon the skull itself. 

The amount of force requisite to break in the nasal bones, at their 
upper third, is very great ; no less, indeed, than is requisite to fracture 
the os frontis. If they do finally yield at this point, then no doubt 
the base of the skull must yield also. Nor do I think patients could 
often be expected to recover from an accident so severe. To this class 
of fractures belongs the specimen contained in my museum, in which 
not only both of the nasal bones are sent in — the nasal spine being 
broken at its base — but also the os frontis is depressed, the nasal pro- 
cesses of the upper maxillary bones are broken and greatly displaced, 
and the anterior half of the cribriform plate of the ethmoid is forced 
up into the base of the brain. If it is meant that in these cases the 
patient is in danger from injury done to the base of the skull through 
the fracture and depression of the ossa nasi, we can appreciate the 
value of the opinion ; but we do not understand how this danger can 
exist when the nasal spine of the os frontis is not broken, and the 
upper ends of the nasal bones are not displaced backwards. But, ad- 
mitting that it were possible in this way to force up the base of the 
skull, it does not seem to me that we ought to attach any value to the 
advice occasionally given, to attempt to restore the broken ethmoid 
by seizing upon the septum and pulling downwards. A force suffi- 
cient to break the base of the skull never fails to comminute and 
detach almost completely the septum nasi. We are to proceed in 
such a case as we would in a case of broken skull. "We must lay 
open the skin freely, and with appropriate instruments seek to elevate 
and remove, if necessary, the fragments. Indeed, after such accidents, 
we shall generally see plainly enough that death is inevitable, and that 
our services will be of no value. 

Occasionally, I have observed, the bones are neither broken at their 
lower ends nor through their central diameters, but only at their 
lateral, serrated, or imbricated margins. This is rather a displace- 
ment, or dislocation, than a fracture. It is more likely to happen, I 
think, in childhood than in middle or old age, as in the following- 
example: — 

Thomas Kelley, aged four years, was kicked by a horse. Two 

1 Report on Deformities after Fractures, Cases 16 and 18. 



94 FRACTURES OF THE NOSE. . 

hours afterwards, when he was first seen by a surgeon, the nose and 
face were much swollen, and the fracture was overlooked. 

One year after the accident, I found both nasal bones depressed 
through nearly their whole length, and especially in their lower halves. 
The right nasal process was also much depressed, and the right nostril 
obstructed. The lachrymal canals upon this side were closed. 

Sometimes the lower ends of the nasal bones are bent backwards, 
or laterally, constituting a partial fracture. 

A lad, aged ten years, was hit by one of his mates accidentally with 
his elbow, upon the left side of his nose. I was immediately called, 
and found the lower end of the left os nasi displaced laterally and 
backwards, so that it rested under the lower end of the right os nasi. 
There did not appear to be any fracture beyond that which was in- 
evitable by the mere separation of its serrated margins from the bone 
adjoining. The angle formed by the bone at the point where the 
bending had occurred was smooth and rounded, and not abrupt as in 
a complete fracture. 

With a steel instrument, introduced into the left nostril, I attempted 
to lift the bone to its place. The membrane was very sensitive, and 
the patient very restless under my repeated efforts. I pressed up- 
wards with considerable force, and succeeded at length in bringing 
the bone nearly into position. 

If there is more complete displacement, the upper ends are not 
usually forced backwards, but rather a very little forwards, from their 
articulations with the os frontis, and the bones then swing, as it were, 
upon the lower ends of the nasal spine, as upon a pivot. In this con- 
dition they are very firmly locked, and it requires considerable force, 
applied under their lower extremities, to restore them to place. 

Such seemed to be the position of the bones in the case of the lad 
Kelley, already mentioned, and also in a German, whose nose was 
flattened by a severe blow when he was eleven years old, whom I saw, 
thirteen years after the accident, in the Buffalo Hospital. In this last 
example the bones were very much displaced backwards. 

In children, also, the nasal bones may be spread and flattened, the 
lateral margins not being depressed or displaced, but only the mesial 
line or arch forced back, so as to press aside the processes of the supe- 
rior maxilla ; which deformity may become permanent. 

A block of wood fell upon a child three weeks old, as she was lying 
in the cradle. The nature of the injury was not understood by the 
parents, and no surgeon was called. The ossa nasi are now, twelve 
years after the accident, much wider than is natural, and depressed ; 
the nasal processes of the superior maxilla appearing to have been 
spread asunder. 

Jacob Kibbs, a German, aged seven years, fell from a height of forty 
feet, striking on his face. His parents did not suspect the injury, and 
no surgeon was called. Twenty -four years after this, I found the nose 
almost flat. The nasal bones appeared unusually wide, and were 
sunken between the processes of the upper maxillary bones, which 
latter might be recognized by two parallel ridges on each side, slightly 
rising above the level of the ossa nasi. 



FRACTURES AND DISPLACEMENTS OF SEPTUM NAEIUM. 95 

Benjamin Bell and others have spoken of tedious ulcers, polypi, 
necrosis, fistula lachrymalis, abscesses, impeded respiration, and im- 
pairment of the sense of smell and of speech, as circumstances apt to 
result from these injuries, and it is certain that such consequences have 
occasionally followed; but they must sometimes be regarded as acci- 
dents due to the state of the general system, and as having no connec- 
tion with the fracture, except as this injury served to awaken certain 
vicious tendencies. 

Two years ago, a gentleman, then twenty-five years old, was struck 
accidentally upon the right side of his nose by a board, and the ossa 
nasi were displaced to the left. A surgeon made an attempt to reduce 
them, but did not succeed, and they have remained displaced ever 
since. 

The nose for a time was much swollen. A few months after the 
accident, a purulent discharge commenced from the right nostril, and 
at length an abscess formed in the right cheek. The abscess is now 
healed, but the nose continues to discharge pus, and occasionally it 
bleeds freely. There is a perforation of the septum, of the size of a 
three-cent piece, which is continuing to enlarge. 

~No hereditary maladies exist in the family, except that, on his father's 
side, it has been generally observed that wounds do not heal kindly. 
The same is the fact with him. When a child, he was also very sub- 
ject to epistaxis; at sixteen, a pulmonary difficulty began, and he had 
more or less cough, with haemoptysis, for two years. Since then, his 
health has been good. He is a lawyer by profession, but of late he 
has lived in the country, upon a farm, and has accustomed himself to 
much out-door exercise. 

As to the prognosis in these fractures, I can only say that either 
owing to the ignorance and carelessness of the patients themselves, 
who neglect to call a surgeon in time, or to the difficulty of diagnosis, 
or to the greater difficulty in maintaining an adjustment of the frag- 
ments, it has hitherto happened that, after a fracture of the ossa nasi, 
more or less deformity has usually remained. I have seen but five 
which could be said to be perfectly restored. 



§ 2. Fractures and Displacements of the Septum Narium. 

Fractures or displacements of the septum narium must occur to 
some extent in all fractures of the ossa nasi accompanied with depres- 
sion ; but they are also occasionally met with as the results of a blow 
upon the nose, which has been insufficient to break the bones, and in 
which only the cartilaginous portion of the nose has been bent inward 
upon the septum. 

Of these simple, uncomplicated accidents, I have seen eight; in 
four of which no surgeon was employed, or surgical treatment of any 
kind adopted, and it is quite probable that only in a small proportion 
of all the cases was the nature of the accident recognized. Such, at 
least, has been generally the statement of the patients themselves. 
The same causes will explain this which have been invoked to explain 



9(5 FRACTURES OF THE NOSE. 

similar oversights in cases of broken ossa nasi. To which we may 
add. as an additional reason why it may be overlooked, the frequency 
of lateral distortions or deviations in the natural development of this 
septum. 

The cartilaginous portion of the septum is that which is most fre- 
quently displaced by violence, and then it is usually at the point of 
its articulation with the bony septum. Next, in point of frequency, 
the perpendicular nasal plate is broken, and especially where it ap- 
proaches the vomer. TTe omit in this enumeration, of course, those 
cases where the nasal bones themselves are broken down, in m<: - 
all of which, as we have already sail the perpendicular plate is more 
or less fractured and displaced. TTe cannot say how often the vomer 
is broken, since it is beyond our observation, except in autopsies. It 
is probable, however, that the force of the concussion rarely reaches 
it, the cartilage or the perpendicular plate giving way first and easily. 

Where the deviation is only lateral, the results are less serious, yet 
sufficiently so, in a few instances, to demand our attention. Lateral 
obliquity of the lower portion of the nose follows generally, but not 
uniformly, a lateral displacement of the cartilage, and when it does 
exist, it is not always proportioned to the amount of displacement 
existing in the septum, so that the septum is then made to project 
obliquely across the nasal passage, causing often a serious obstruction 
and permanent inconvenience. In one instance, also. I have known it 
to occasion a chronic catarrh. 

A lad. set. 15. was struck violently on the nose, which- became im- 
mediately much swollen, but no surgeon was called. Eight years 
after, I found the septum displaced laterally, and to the left side, pro- 
ducing also a slight lateral inclination of the end of the nose. He 
was unable to breathe freely through the left nostril, and from the 
same side a catarrhal discharge had continued from the time of the 
accident. 

The following example, in which the accident has been followed by 
a morbid condition of the cutaneous glands, is of more difficult ex- 
planation : — 

A young man. a?t. 23. called upon me, supposing that he had a 
polypus nasi. I found that in consequence of a fall upon the ice, seven 
years before, the septum narium had been displaced to the right so as 
to almost completely close this nostril. In very cold weather, when 
the vessels of the membrane are contracted, the passage is more free. 
The left nostril is proportionably wide. 

During the last four or five years, the right side of his face has been 
subject to profuse perspiration. I: is almost constant in summer, and 
only occasional in winter. The line of division between the perspir- 
ing and non -perspiring portions of the face passes perpendicularly 
from the top of the centre of the forehead, along the ridge of the nose, 
and down to the centre of the chin. The phenomenon is due, perhaps, 
to an increased vascularity in the right side of the face : possibly to 
some peculiarity in the condition of the nervous trunks, occasioned by 
the nasal obstruction. 

A depression of the cartilage forming a portion of the ridge of the 



FKACTURES AND DISPLACEMENTS OF SEPTUM NARIUM. 97 

nose is necessarily accompanied with a corresponding degree of late- 
ral displacement, with or without fracture, of its perpendicular portion, 
and produces, therefore, not only great deformity, sometimes a com- 
plete flattening of the end of the nose, but, also, in some instances, 
complete obstruction of the nostrils. 

We conclude, from all that we have seen, that fractures and displace- 
ments of the septum narium are generally followed by permanent 
deformity, and occasionally with still more serious results. We sug- 
gest, therefore, a more careful examination in recent injuries, with a 
view to the ascertainment of its lesions, and it would be well, cer- 
tainly, if we could devise some reliable mode of treatment. 

It is doubtful whether a partition so thin and unsupported can ever 
be well adjusted and supported by artificial means. We possess, how- 
ever, one advantage in the treatment of this accident which we do not 
in the treatment of broken ossa nasi, viz : facility of observation and 
of approach, and if we can do little with plugs and supports in the 
one case, we may possibly do more in the other. Nothing seems 
more rational, then, than to plug carefully and equally each nostril, 
with pledgets of lint, while we cover the outside of the nose completely 
with a nicely moulded gutta-percha splint or case, which ought to be 
made to press snugly upon the sides, and permitting these to remain 
for several weeks, or until the cure is completed. The papier mache 
of Dzondi, employed by him in cases of broken ossa nasi, would be 
equally applicable here ; but the gutta percha, as being more plastic, 
and hardening more quickly, ought to be preferred. 

Attempts to remedy the deformities of the nose at a later period, 
belong to the department of anaplastic surgery, and the modes of pro- 
cedure must be varied according to the circumstances of the case. 

The following example will serve as an illustration of what may 
sometimes be accomplished in these cases : — 

A young man fell from a two-story window, striking upon his face, 
A surgeon was called, but he did not discover the nature of the injury 
to the nose. 

One year after the accident he called upon me for relief. The car- 
tilaginous portion of the septum was broken just at the ends ®f the 
nasal bones, and forced backwards about three lines, producing a strik- 
ing depression at this point of the ridge of the nose, while at the same 
time the end of the nose was thrown up. The deformity was very 
unseemly, and annoying both to himself and to his friends, who at 
first could scarcely recognize him. 

I introduced a narrow, sharp-pointed bistoury through the skin of 
the nose on the right side, and resting its edge upon the ridge at the 
junction of the cartilage with the ossa nasi, I cut the cartilaginous sep- 
tum directly backwards about three lines, and then making a gradual 
curve with my knife, I cut downwards about eight lines towards the 
end of the nose. The intercepted portion of cartilage could now be 
easily lifted with a probe, and the line of the ridge of the nose com- 
pletely restored. It was at once apparent, also, that lifting the cartilage 
would depress the tip of the nose and restore its symmetry. 

To retain the cartilage in place, I constructed a gutta-percha splint 



98 FEACTUEES OF THE MALAE BONE. 

of the length and shape of the nose, but so formed along its middle as 
that it would not press upon the cartilage which I had lifted, resting 
well upon the ossa nasi, but not touching the ridge from the lower 
ends of these bones to the tip of the nose, at which latter point it again 
received support. I now passed a needle, armed with a stout ligature, 
through the upper end of the uplifted cartilage, transfixing, of course, 
the skin on both sides of the nose, and this I tied firmly over the splint. 
This accomplished the important object of pressing backwards and 
downwards the tip of the nose, and thus tilting up the upper part of 
the ridge and septum, and of more effectually securing the cartilage 
in place by lifting it directly with the ligature. On the second day 
the ligature was removed, but the splint was continued two weeks, 
during most of which time a band was kept drawn across the lower 
end of the splint, and tied behind the neck. 

To prevent the cartilage from falling back when final cicatrization 
occurred, I pressed the sides of the splint firmly towards each other, 
just below the incision, so as to force as much as possible the walls of 
the nares into the fissure of the septum, made by lifting it up. 

The result is a complete and perfect restoration of the nose to its 
original form. 



CHAPTEE IX. 

FRACTURES OF THE MALAR BONE. 

I HAVE been unable to find any records of a simple fracture of the 
malar bone, that is to say, of a fracture unconnected with a fracture of 
other bones of the face. It is probable, however, that it sometimes 
occurs, but that not being accompanied with much displacement, it is 
overlooked. I have myself seen a fracture of the upper margin, or of 
that portion which constitutes a part of the orbital border, in two or 
three instances, while I was unable to detect any other fracture among 
the bones of the face ; but it is by no means certain that other fractures 
did not exist, perhaps in some of the bones which form the socket, or 
in the superior maxilla, as mere fissures, or as fractures with only 
slight displacement. The prominence of the malar bone, and especially 
the sharpness of its orbital margin, would enable the surgeon to detect 
easily the smallest displacement, or even a fissure, while a much more 
extensive displacement elsewhere would escape detection. 

The two upper maxillary bones form, as they are placed opposite 
to each other, an irregular arch, one end of which rests upon its fellow, 
at the intermaxillary suture, and the other end rests upon the nasal 
and frontal bones ; while over the centre of the arch is situated the 
malar bone. The force of a side blow upon the malar bone will ex- 
pend itself therefore chiefly upon the base of the maxillary apophysis, 
as being in the line of the direction of the force. The force continuing 



FRACTURES OF THE MALAR BONE. 99 

to act, after the apophysis is broken, the portion of the superior maxilla 
above the floor of the nares will fall inward toward the septum, while 
the portion below will tilt outward and open the intermaxillary suture 
along the roof of the mouth. This suture will also open more widely 
in front than behind, owing to the greater depth of the suture in front. 

These observations I have verified by several experiments made 
with a hammer upon a clean skull. 

One might suppose that it would be a very easy matter to restore 
these bones to place upon the naked skull, after such an accident. 
Certainly it would be very desirable to do so ; were this accident to 
occur to any patient, since the malar bone is slightly depressed, the 
nostril upon this side is nearly closed, and the line of the teeth is 
disturbed, and it is possible also that an opening might be established 
between the nose and mouth immediately back of the incisors. In 
fact, however, I found the restoration impossible. It could not be 
accomplished by an instrument within the nose pressing outward, nor 
by pressing inward upon the teeth and alveoli ; not certainly without 
very great and unwarrantable force. The difficulty consisted simply 
in the antagonisms of the serrated margins of the intermaxillary 
suture, which projecting one or two lines on each side, could not be 
made to interlock again, but were firmly braced against each other. 

I shall not find it necessary to report in detail the results of the 
experiments, but shall content myself with stating that by the second 
blow, in the last experiment, the skull was also found broken at its 
base through the lesser wings of Ingrassias ; the force of the blow 
having been conveyed, apparently, along the orbital plate of the supe- 
rior maxilla and os planum. 

This is the only example from four experiments in which the frac- 
ture extended through the dental arcade, and it was the result of the 
first blow. The fracture of the base of the skull by the second blow 
indicates the possibility of producing a fatal lesion of the brain or of 
its bloodvessels by a blow upon the malar bone. 

General Summary. — A fracture of the superior maxilla has occurred 
in every instance ; and twice when the malar bone was not broken : 
in each of the two last cases the antrum alone was broken, and the 
depression of the malar bone was scarcely noticeable. In the second 
of these cases, the fracture extended also through the dental arcade. 

In three cases the nasal apophysis has broken near the base, and in 
one case at two points. One of the three fractures of the nasal apo- 
physis was accompanied with a diastasis of the superior maxilla 
through its intermaxillary suture. 

The malar bone has been broken twice by the first blow, and always 
when the blow has been repeated. The orbital margin and orbital 
plate have been fissured twice, the outer portion of the orbital plate 
being pushed a little into the socket. Once this plate has been pushed 
downwards. 

The zygoma has been broken three times, and always transversely, 
a little beyond its centre, or where the bone is the most slender and 
most convex. 



100 FRACTURES OF THE MALAR BONE. 

The ethmoid has been broken three times ; and always longitudinally 
through the orbital plate. 

The sphenoid has been broken once, at the base of the skull. 

In addition to these observations upon the naked skull, I have seen 
at least four examples, which illustrate the relative infrequency of 
fractures of the malar bone, as compared with fractures of the superior 
maxilla and of the other bones of the face, even when the blow is 
received directly upon the malar bone. 

Pat. Maloney, set. 55, fell about twenty feet and struck upon his 
face. Six weeks after the accident, while an inmate of the Buffalo 
Hospital of the Sisters of Charity, I found the right malar bone de- 
pressed, but I could not trace any line of fracture in the malar bone. 
I think the antrum of the superior maxilla was broken and the malar 
bone forced in upon it. 

Thomas Crotty, set. 20, was struck with a hoop, August 15, 1855. 
He was seen immediately by a surgeon in Canada, but the fracture 
was not recognized. Five days after he called at my office. I found 
the outer portion of the right malar bone lifted slightly and the lower 
and anterior angle depressed about three lines, as if this portion had 
been forced in upon the antrum. 

The third case will be found reported under fractures of the superior 
maxilla, and the fourth has recently been brought under my notice 
in the practice of Dr. Wadsworth of this city, the fracture having 
been occasioned by collision with the head of another man. 

Prognosis. — The malar bone may be depressed, as we have seen, to 
the extent of two or three lines, without being broken. This accident 
will be more properly considered under fractures of the upper maxilla. 
A fracture of the malar bone implies, therefore, generally, that great 
force has been applied, and that other fractures exist as complications. 
This may not be true, however, when only the orbital margin of the 
socket is - broken. If the orbital plate is broken, and a portion of it is 
pushed into the socket, it may occasion a slight protrusion of the ball, 
as in two cases related by Dr. ISTeill as fractures of the upper maxilla, 
and as has been noticed in the experiments already referred to. This 
protrusion of the eyeball will probably continue in some degree, as 
long as the bones remain displaced. It is quite probable, however, 
that in some cases, after severe injuries of the face, a moderate pro- 
trusion of the eyeball is due entirely to extravasation of blood in the 
socket; a circumstance which would be likely to follow a fracture of 
the bones of the socket, and to increase temporarily the protrusion of 
the eye. 

If the body of the bone is broken entirely through, and coma super- 
venes upon the accident, there is some reason to fear that the skull is 
fractured at its base, and the prognosis ought to be grave. 

Treatment. — If there is only a fissure of the orbital margin, it will 
not require attention ; but if the fissure extends through the orbital 
plate and at the same time the anterior and inferior margin of the 
bone is depressed, in consequence of which the orbital plate is tilted 
upward and made to push forward the eyeball, the propriety of 
surgical interference may be considered. If this protrusion is con- 



FRACTURES OF THE UPPER MAXILLARY BONES. 101 

siderable, and evidently due to the displaced bone, an attempt should 
be made to lift the body of the malar bone and thus to restore to 
position its orbital plate. The method of accomplishing this I shall 
describe particularly when speaking of fractures of the superior 
maxilla with depression of the malar bones. 






CHAPTEE X. 

FKACTUEES OF THE UPPER MAXILLARY BONES. 

These fractures assume so great a variety in respect to form, situa- 
tion and complications, that it would be impossible to speak of them 
systematically or to establish anything but very general rules as to 
treatment and prognosis. 

They may be broken, or loosened from each other or from the other 
bones with which they are articulated, with or ■ without any farther 
fracture ; the nasal processes may be broken, and generally this acci- 
dent is accompanied with a fracture of the nasal bones also ; the malar 
bones may be forced in, carrying with them a portion of the outer wall 
of the antrum ; the alveoli may be broken and more or less completely 
detached; and either of these several fractures may be complicated with 
fractures of the other bones of the face or of the base of the skull even. 

Treatment. — When the harmonies of the upper maxillary bones are 
only slightly disturbed, nothing but a retentive treatment is necessary. 

A man was thrown backward from a loaded cart, one wheel of the 
cart passing over his face. He was taken, up unsconscious, but when 
I saw him on the following morning, his consciousness had returned. 
The right malar bone was broken and forced down upon the antrum 
about three lines. Both superior maxillae were loosened from their 
articulations, and could be moved laterally, the motion producing a 
slight grating sound. The same motion and grating occurred when- 
ever he attempted to swallow. No effort was made to elevate the 
malar bones, nor did I find any means necessary to retain the maxil- 
lary bones in place, the amount of displacement being very incon- 
siderable, and never sufficient to be observed by the eye. Cool lotions 
were applied constantly to the face, and the patient was sustained by 
a liquid diet. On the ninth day all motion of the fragments had 
ceased, and on the twenty-seventh day the patient was completely 
recovered, with only the depression of the malar bone remaining. 

Sargent, of Boston, reports a similar case, in which a slight separa- 
tion of the maxillary bones united promptly and without any reten- 
tive apparatus. 1 

But in a case in which the superior maxillary bones had been more 
completely torn from their connections, complicated with other severe 

1 Boston Med. and Surg. Journ., vol. lii. p. 378. 



102 FRACTURES OF THE UPPER MAXILLARY BONES. 

injuries, I found it necessary to support the fragments by closing the 
lower jaw upon the upper, and by suitable bandages. The patient 
died, however, on the twelth day. 1 

Graefe recommends, where the bones are thus extensively separated 
and displaced, an apparatus made of steel, and suitably covered, which 
is to be applied against the forehead and buckled "under the occiput. 
From the two sides descend a couple of steel plates, which, having 
arrived at the free border of the upper lip, are reflected upon them- 
selves, and are made to support upon their extremities long silver 
gutters, intended for the reception of not only the displaced teeth and 
alveoli, but also those teeth which are firm. 2 

Wiseman having been summoned to a child with his whole upper 
jaw forced in, by the kick of a horse, "beating the ethmoides quite in 
from the os cribriform," and forcing the palate bone against the back 
of the pharynx, found great difficulty in securing a permanent read- 
justment. At first he attempted to introduce his finger back of the 
bone, but failing in this he bent an instrument into the form of a hook, 
and passing it between the bone and the pharynx, he easily replaced 
the fragments. But, on removing the instrument, they were again 
displaced. Immediately he had constructed an instrument by which 
the bones could be not only easily reduced, but also retained in place, 
extension being made by the hands of the child, his mother and others, 
alternately. In this way the reunion was finally effected, and " the 
face restored to a good shape, better than could have been hoped for." 3 . 

Harris, of New York, mentions a case in which a child, two years 
old, having fallen from a height of fifty feet upon the pavement, was 
found to have a diastasis of both the superior maxillary and palate 
bones; the separation being sufficient to admit the little finger, and 
extending from between the alveoli which supported the central in- 
cissors, to the soft palate. It is not said whether any efforts were made 
to reduce the bones, but six weeks after the injury was received, they 
were still open, and it was proposed to close the space by a plastic 
operation as soon as the condition of the patient would warrant such 
a procedure. 4 

I suspect that in this example, as in my experiments referred to 
under fracture of the malar bone, it was found impossible to adjust 
the bones and close the intermaxillary suture, and for the same 
reasons. 

If, in consequence of a blow received upon the ossa nasi, the nasal 
processes of the superior maxillae are broken down, they may be lifted 
and adjusted in the same manner as the ossa nasi. 

I have seen several examples of this accident, and I have in my 
cabinet a specimen, in which the nasal bones being driven in by the 
kick of a horse, the nasal process upon the left side is broken off just 
above the root of the cuspid tooth, and its upper end inclined inward 

1 Report on Deformities after Fracture. Trans. Amer. Med. Association, vol. viii. 
p. 375, Case IV. 

2 Traite des Frac, etc., par. L. F. Malgaigne, p. 373. 

3 Chirurgical Treatises, by Richard Wiseman, 1734, p. 443. 

4 New York Journ. Med., vol. xiii., 2d ser., p. 214. 



FRACTURES OF THE UPPER MAXILLARY BONES. 103 

toward the nasal passage and backward, until it is completely buried. 
In this situation it has become firmly united to the bony and soft 
tissues into which it was brought in contact. 

The following example will illustrate some of the complications and 
difficulties connected with a depression of the malar bone, and conse- 
quent fracture of the antrum maxillare. 

M. P., of Colesville, aged about 34 years, was thrown from a height, 
striking upon his face, forcing the right malar bone down upon the 
antrum of the superior maxilla. Dr. L. Potter, of Varysburg, and 
myself were called. 

The deformity produced by the sinking of the malar bone was 
very striking, and both the patient and myself were very anxious to 
have it remedied if possible. We found some of the teeth upon the 
side of the fracture loose, and we determined to extract them, and 
press up the bone with an instrument introduced through the empty 
sockets. The first attempt to extract a molar tooth, however, brought 
down several teeth, and the whole floor of the antrum. The detach- 
ment of this fragment was also now so complete that we believed it 
necessary to remove it entirely, a labor which was accomplished with 
infinite difficulty, and with no little hazard to the patient, as dissection 
had to be extended very far back into the throat, and in the end it 
was not effected without bringing out, attached to the fragment of 
maxillary bone, a considerable portion of the pyramidal process of 
the os palati. 

The time occupied in this operation was at least one hour, during 
which we were every moment in the most painful apprehensions lest 
we should reach and wound the internal carotid, which lay in such 
close juxtaposition to the knife that we could distinctly feel its pulsa- 
tion. After its removal the hemorrhage was for an hour or more 
quite profuse, and could only be restrained by sponge compresses 
pressed firmly back into the mouth and antrum. 

When the hemorrhage was sufficiently controlled, we proceeded to 
examine the antrum, the floor of which being removed entire, per- 
mitted the finger to enter freely. The restoration of the malar bone 
was now accomplished without much difficulty, and with only mode- 
rate force. 

Two years after the accident the face presented, externally, no 
traces of the original injury. The malar bone seemed to be as promi- 
nent as upon the opposite side, and there was no perceptible falling 
in where the teeth and alveoli were removed. During several months 
after the removal of the bone, the antrum continued to discharge pus, 
but at length a semi-cartilaginous production closed in the cavity 
below, entirely reconstructing its floor, and the discharge ceased. 
Since then he has experienced no further inconvenience. 

I wish to propose two or three expedients for lifting the malar bone 
when it has been thrust down, which may in certain cases be substi- 
tuted for the mode which has been heretofore generally adopted. 

In many instances, no difficulty will be experienced in resorting to 
the usual method. The recent loss of one or more teeth opposite the 
floor of the broken antrum, or the complete displacement of a tooth, 



104 FKACTUKES OF THE UPPEE MAXILLAEY BONES. 

by the accident itself, will give an opportunity for the perforation of 
the antrum through the open socket, and for the introduction of a 
suitable instrument for lifting the depressed bone. Unless, however, 
the opening is quite large, the instrument employed must be so small, 
such as a straight steel sound or a female catheter, as to expose the 
parts against which its end is made to press, to some risk of being 
broken and penetrated. It is even possible in this way to penetrate 
the socket of the eye, and thus inflict serious injury upon the eye 
itself. Yet, with some care, such accidents may be avoided, and it is 
probable that in the cases supposed, where the sockets of the teeth 
opposite the base of the antrum are open, this method will continue 
to have the preference. 

But if the teeth remain firm in their places, or if they have been 
some time removed, and the sockets are filled up, and we wish to enter 
the antrum at its base, we must either drill through its anterior wall 
above the roots of the teeth, or we must proceed to extract a tooth. 
The first method gives an inconvenient opening, and one through 
which it will be necessary to use a curved instrument; but yet it is a 
method far less objectionable than the extraction of a tooth which is 
firm, or which is even tolerably firm in its socket, and which may 
require the forceps for its removal. The objections to this latter pro- 
cedure were suggested by the tedious and painful operation already 
detailed. The first attempt to extract a tooth brought down the whole 
floor of the antrum, with all its corresponding teeth, and the pyramidal 
process of the palate bone. The tooth was already loose, and we 
thought it might easily be taken out, but it had not occurred to us that 
it was loosened by the comminuted condition of the walls of the antrum, 
and of the dental arcade. The experiments made upon the dead sub- 
ject would seem to show that this fracture and comminution of the 
alveoli is not a very frequent result of a fracture of the antrum pro- 
duced by a blow upon the malar bone, yet it may happen, and when- 
ever it does, the attempt to extract a tooth must always expose the 
patient to the same hazards. Certainly it is no trifling matter to pull 
away all of a man's upper teeth upon one side, and to open freely into 
a broad cavity which might never close again, and which, in this 
event, must always serve as a place of lodgment for particles of food, 
and for foul secretions, to say nothing of the external deformity which 
it is likely to produce, and of the severity and even danger of the 
operation. 

I wish, then, to suggest certain procedures, the value of which I have 
not yet had an opportunity to determine by any experiment upon the 
living subject, but which I have carefully and frequently tested upon 
the dead. 

First, we ought to attempt to lift the bone by putting the thumb 
under its zygomatic process and body within the mouth. If the bone 
is thrown directly downward, or downward and backward, this method 
can scarcely fail ; and even when it is thrown downward and forward 
so as to press into the antrum, it is likely to succeed. If, however, 
for any reason, the thumb cannot be brought to bear upon its under 
surface, we may make a small incision upon the cheek over the ante- 



FRACTURES OF THE UPPER MAXILLARY BONES. 105 

rior margin of the masseter muscle, where its insertion into the malar 
bone terminates, and pushing a strong blunt hook under the bone, we 
may lift it with ease. 

Where the depression of the malar bone is in the direction of the 
anterior and superior angle these means may not be found available, 
and we may then employ a screw elevator, an instrument which I find 
already constructed in a case of trephining instruments made for me 
by Mr. Liier, of Paris, and which I have often used and constantly 
recommended to my pupils, in certain cases of fractures of the skull. 
The instrument ought to be made of the best steel, and with a broad, 
sharp-cutting thread. A slight incision being made through the skin, 
and down to the centre of the malar bone, the elevator is then screwed 
firmly into its structure, and now its elevation and adjustment may be 
accomplished with the greatest ease. 

Malgaigne remarks: "In all complicated fractures of the upper 
jaw, there is one principle which surgeons cannot too much study, 
namely, that all fragments, however slightly adherent they may be, 
ought to be most carefully preserved, and they will be found to unite 
with wonderful ease. This remark had already been made by Saviard. 
Larrey insists strongly upon it, and we have seen that M. Baudens, 
so great an advocate for the removal of loose fragments, has declared 
for these fractures a special exemption." 1 

Malgaigne has here especial reference to fractures of the dental 
arcade, and to fractures implicating the alveoli and extending more or 
less into the body of the bone. 

It would be an error, however, to suppose that a reunion will in 
these cases uniformly take place. Exceptions have occurred in my 
own practice, the fragments becoming loosened and completely de- 
tached after the lapse of several weeks. In the case related by Miller, 
the whole floor of the antrum having been broken oft* in an unskilful 
attempt to extract the second right upper molar, it was found impos- 
sible to make it unite, and it was subsequently removed. 2 Such 
unfortunate results certainly may sometimes be reasonably anticipated. 
Yet they occur so seldom as to justify the opinions and practice 
advocated by Malgaigne. 

In some instances, where fragments are displaced carrying with 
them several teeth, while others in the same row remain firm, it will 
be sufficient to close the mouth and apply a bandage as for fracture of 
the inferior maxilla; in others, the teeth and their alveoli ought to be 
fastened with silk, or gold or silver thread; or gold or silver clasps 
may be applied, or gutta percha moulded to the teeth and jaw. 

In a case of fracture of the right superior maxilla, reported by 
Baker, of Norwich, N. Y., complicated with a fracture of the inferior 
maxilla, the alveoli were retained in place very perfectly by a mould 
of gutta percha. 3 Neill, of Philadelphia, has also reported three cases 
of fracture of the bones of the face, involving the superior maxilla,. 

1 Op. cit., vol. i. p. 376. Paris ed. 

2 News Letter, April, 1854. Also, Bost. Med. and Surg. Journ., vol. li. p. 246. 

3 New York Journ. of Med., vol. i., 3d ser., p. 362. 

8 



106 FRACTURES OF THE ZYGOMATIC ARCH. 

in two of which the eyes were made to protrude more or less from 
their sockets. 1 The loosened alveoli were made fast by wire. The 
subsequent deformity was inconsiderable, yet in no instance was the 
restoration complete. 2 The same method was adopted successfully by 
a surgeon in Virginia, in the case of a negro fifty years old, where most 
of the teeth of the left upper jaw were forced into the mouth, carrying 
with them their corresponding alveolar processes. The teeth remained 
firm in their sockets, but the separation of the bone was complete, the 
fragment being held in place only by the mucous membrane of the 
mouth. On the eighth day the surgeon found that the negro had 
removed the wire, and also the cork from between his teeth, and the 
maxillary bandage; but the soft parts had already united, and the 
bones showed no tendency to displacement. His recovery was speedy, 
and it was accomplished without any farther treatment. 3 

Our experience during the war of the rebellion in this country con- 
firms most of the observations heretofore made in relation to these 
fractures. Owing to the extreme vascularity of bones composing the 
upper jaw the fragments have been found to unite, after the most 
severe gunshot injuries, with surprising rapiditj T ; the amount of 
necrosis and caries being usually inconsiderable, compared with 
the amount of comminution. The same anatomical circumstances, 
namely, the vascularity, has rendered these accidents peculiarly liable 
to troublesome hemorrhages, both primary and secondary. 

The Surgeon-General reports that of 4167 wounds of the face tran- 
scribed from the reports from the beginning of the war to October, 1864, 
there were 1579 fractures of the facial bones, and of these 891 re- 
covered, 107 died— the terminations are still to be ascertained in 581 
cases. He further remarks that secondary hemorrhage has been 
the principal source of fatality in these cases, and that frequent recourse 
has been had to ligation of the carotid, with the result of postponing 
for a time the fatal event. 4 



CHAPTEE XI. 

FRACTURES OF THE ZYGOMATIC ARCH. 

The zygoma, strictly speaking, is formed in a great measure by the 
body of the malar bone, and it is broken whenever the malar bone is 
completely separated through any portion of its body; but I propose 
to confine my remarks to that portion only which is composed of the 

1 See " Observations," under Fractures of the Malar Bone ; in which the orbital 
plate of the malar bone was pushed into the sockets. 

2 Phil. Med. Exam., vol. x., new ser., pp. 455-8. 

3 Amer. Med. Gazette, vol. viii., new ser., p. 106. 

4 Circular Xo. 6, Washington, Nov. 1, 1865, p. 20. 



FRACTURES OF THE ZYGOMATIC ARCH. 107 

two processes, called respectively the zygomatic processes of the malar 
and temporal bones. 

Duverney relates a case in which a young child, having in. his 
mouth the end of a lace spindle, fell forwards and thrust the spindle 
through the mouth from within outwards, breaking the zygoma in the 
same direction, and leaving the fragments salient outwards. 1 To which 
case of outward displacement Packard, in a note to Malgaigne's work 
on fractures, &c, has added a second. 2 

I know of no other examples in which the fragments have been 
thrust outwards. A reference to my experiments upon the naked 
skull will, however, show that the zygoma may be broken and dis- 
placed in the same direction, by any force which shall fracture the 
superior maxilla, and depress the anterior margin of the malar bone. 
In my experiments this has happened three times, and always at the 
same point, viz., a little beyond the middle of the zygoma, near where 
the suture which joins the two processes terminates below. The 
fractures were always transverse, and not in the line of the suture. 
They were therefore fractures of that portion of the zygoma which 
belongs to the temporal bone. 

I suspect, also, that to this class of cases belongs the example related 
by Dupuytren, in which the patient having died on the fifth day, from 
the effects of the cerebral concussion, the autopsy disclosed " a fracture 
through the zygomatic arch; and that part of the superior maxillary 
bone which constitutes the antrum was driven in." 3 

In another case mentioned by Dupuytren, produced by a direct 
blow, the fracture was compound and comminuted, and although the 
fragments were raised easily by an elevator, suppuration ensued be- 
neath, and the matter was discharged within the mouth. 4 

Tavignot reports a case of fracture of this arch which was not dis- 
covered until after death, the fragments not being at all displaced. 5 

Dr. John Boardman, one of the surgeons to the Buffalo Hospital of 
the Sisters of Charity, informs me that he has met with a fracture of 
the zygoma in a man about thirty years of age, occasioned by a blow 
from a cricket ball. Dr. Boardman saw him on the fourth day, and 
ascertained that immediately on the receipt of the injury he felt 
slightly stunned, and that he soon recovered from this, but was unable 
to open his mouth except by pulling it open with his hand; neither 
could he close it except in the same manner. This immobility of the 
jaw continued several days with only very slight improvement; at 
the end of five weeks, however, when last seen, the mobility was 
nearly, but not quite restored. The depression, a little in front of the 
centre of the zygoma, was discovered by the patient himself imme- 
diately after the receipt of the injury, and he says he tried at once to 
ascertain whether he could not push the fragments back by moving 
the jaw. He was unable to make any impression upon them by this 

1 Bulletin de la Societe Anatomique, p. 138, 1810. 

2 Op. cit., p. 289, vol. i. 

3 Injuries "and Diseases of Bones, by Baron Dupuytren. Syd. ed., London, 1S47, p. 
336. 

4 Op. cit., p. 335. 5 Bulletins de la Soc. Anat., 1810, p. 138. 



108 FKACTUKES OF THE ZYGOMATIC ARCH. 

manoeuvre. The depression still remains, but it is not so distinct as 
it was when first seen. 

Symptoms. — An irregular projection or depression of the fragments 
is the only sign which can be relied upon to indicate the existence 
of this accident ; and this must often be concealed by the swelling 
which follows so rapidly wherever the integuments are severely bruised 
over a superficial bone. This displacement can scarcely occur in but 
two directions, either outwards or inwards; since the attachments of 
the temporal aponeurosis above, and of the masseter muscle below, 
must effectually prevent its descent or ascent. 

Neither motion nor crepitus will often be present. In some few 
cases the difficulty in opening or shutting the mouth, occasioned by 
the projection of the fragments towards or into the tendon of the 
temporal muscle may assist in the diagnosis. 

Prognosis. — If the fracture has been produced indirectly by a de- 
pression of the malar bone, the prognosis must depend upon the 
amount of injury done to the other bones of the face; in itself, the 
fracture of the zygoma cannot be a matter of any moment. The same 
remark might apply also to any fracture of the zygoma in which the 
angles were salient outwards. If, on the contrary, the angle is salient 
inwards, the fracture having been produced by a blow inflicted directly 
upon the zygomatic arch, from without, or by a blow upon the outer 
portion of the malar bone, it may, perhaps, occasion some embarrass- 
ment to the action of the temporal muscles. 

If the force which produces the fracture has acted more upon the 
temporal portion of the arch, near where the process arises from the 
temporal bone, it may be accompanied with a fracture of the skull, 
and with serious cerebral lesions, as in one of the cases already alluded 
to as having been noticed by Dupuytren. 

The abscess which followed in the case of the compound, comminuted 
fracture, quoted from the same author, indicates the danger of this 
complication ; but it must be noticed that its evacuation resulted in a 
rapid cure, and that no deformity or difficulty in moving the jaw re- 
mained. 

Treatment. — A fracture, accompanied with an outward displacement, 
and occasioned by a depression of the malar bone, will be adjusted by 
a restoration of the malar bone in the manner already described, when 
speaking of fractures of the superior maxillary, &c. If the fragments 
are displaced outwards, in consequence of a direct blow from within, 
then they may be replaced by pressing upon the projecting angle. 
In this way Duverney easily reduced the bones in the case which I 
have cited. 

When the fragments, in consequence of a direct blow from without, 
have been driven inwards, and, as a consequence, serious embarrass- 
ment to the motions of the temporal muscle ensues, an attempt ought 
to be made at once to replace them ; if, however, no impediment to the 
action of the muscle exists, it is scarcely necessary to say that no sur- 
gical interference will be required. It is quite probable, indeed, that 
a slight amount of embarrassment may be the result of the direct in- 
jury to the muscle inflicted by the blow, without reference to the dis- 



FKACTUKES OF THE LOWEK JAW. 109 

placement of the bone, and that a few days will suffice to remedy this 
evil entirely ; and, moreover, experience teaches that in the case of a 
fracture in other bones, where the fragments actually penetrate the 
muscles and remain thus displaced, the points are gradually absorbed, 
and rounded, so that after a time they constitute no impediment to the 
action of the muscles. It is proper to infer that the same thing will 
occur here. The surgeon may be reminded, also, that it is not the 
muscle but only its tendon which is liable to be penetrated, and that 
even this is usually protected somewhat by a plate of soft adipose 
tissue. 

If to these considerations we add the difficulties which we shall be 
likely to encounter in the reduction, we shall expect to find but few 
cases in which a resort to surgical interference will be necessary. 

Duverney says that he restored a fracture of this arch, accompanied 
with depression, by pressing against the zygoma from within the 
mouth ; but an examination of the interior of the buccal cavity will 
convince us that this is impossible when the fracture is at any point 
near the middle of the zygoma, and that it can be only when the frac- 
ture is at or near the junction of the zygoma with the body of the 
malar bone that any effective pressure can be made from this direction. 
In such a case, we may, perhaps, lift the portion of the zygoma re- 
maining attached to the malar bone, by the same means which have 
already been suggested for lifting the bone itself. 

If the bone is driven toward the tendon of the temporal muscle at 
or near its centre, as happens almost always, then if its restoration be- 
comes necessary, it can be accomplished only by approaching the bone 
from without. 

Dupuytren found an external wound through which, by the aid of 
a levator, he easily restored the fragments to place. 

M. Ferrier, however, of the Hospital of Aries, in a case brought 
before him, made an incision through the integuments down to the 
bone, and then attempted to slide underneath the small extremity of 
a spatula ; but the aponeurosis would not yield, and he was obliged 
to cut it also. He was now able to lift the fragments easily. The 
wound healed rapidly, and the patient was dismissed without any 
deformity. 1 



CHAPTEK XII. 

FRACTURES OF THE LOWER JAW. 

Division. — Of 33 examples of fracture of this bone which have 
come under my observation and been recorded by me, not including 
gunshot fractures, 31 were broken through some portion of the body. 

1 Bulletin des Sciences Med., torn. x. p. 160. 







110 FKACTUKES OF THE LOWER JAW. 

Of the whole number 13 were broken completely asunder at two or 
more points, constituting double and triple fractures ; and of the re- 
maining 20, 5 were accompanied with detachment of portions of the 

alveoli, and 1 with the detachment 
Fi g- 25 - of a considerable fragment from the 

body. 

From this analysis it will be seen 
that 19 of the 33 were comminuted 
fractures. 12 were compound; not to 
include in this enumeration several 
examples in which the partial or 
complete clislodgment of a tooth 
might entitle them to be called com- 
pound. 

Four fractures through or near 
the symphysis were nearly or quite vertical, and 18 of the remainder 
were known to be oblique. Malgaigne has remarked, also, that in 
fractures of the body of the bone the direction of the obliquity is 
generally such that the anterior fragment is made at the expense of 
the internal face of the bone, and the posterior fragment at the expense 
of the external face : this latter overriding the former. Buck, of New 
York, has seen the fragments in an opposite condition, requiring the 
use of the knife and the saw for their extrication. 1 I have myself 
recorded one similar example, but in which the fragments were easily 
replaced. 

In twenty examples of fractures through the body, not including 
fractures of the symphysis, the line of fracture has been observed to be 
fourteen times at or very near the mental foramen ; twice between the 
first and second incisor ; three times behind the last molar, and once 
between the last two molars. 

Syme, Liston, and Miller have remarked, also, the greater fre- 
quency of fracture near this foramen, but Mr. Erichsen thinks he has 
seen it most frequently broken near the symphysis, between the lateral 
incisors or between these teeth and the canine. Boyer observes that 
it is generally somewhat in front of the foramen; for which reason, as 
he thinks, the dental nerve is rarely torn. 

Says Boyer, in his Traite des Maladies Chirurg 'kales, " A fracture 
never takes place in the central point of the length of the jaw, called 
the symphysis of the chin; but when the solution of continuity occurs 
towards the middle of the bone, it is upon one or the other side of the 
symphysis, which remains always upon one of the fragments." An 
opinion which, however, he does not seem always to have entertained, 
since Eicherand, in a report of his lectures, has made him say that a 
fracture sometimes takes place "near the chin, but seldom so as to 
produce the division of the symphysis of that part, though it be not 
impossible." But many surgeons since his time have noticed this 
fracture, and Malgaigne assures us that J. Cloquet has demonstrated 

1 New York Journ. Med., March, 1847. Proceedings of N. Y. Med. and Surg. Soc, 
Sept. 19, 1846. 



FRACTURES OF THE LOWER JAW. Ill 

its existence upon an anatomical specimen. In the two following 
cases the evidences were so complete that I do not myself entertain 
much doubt as to their character: — 

An Irish laborer, aged seventeen years, was thrown from a wagon, 
breaking the inferior maxilla on both sides through the body, and, 
also, exactly in the centre, vertically, between the central incisors. 

I dressed the jaw with a four-tailed bandage, but found great diffi- 
culty in bringing up the left fragment to a line with the right. I 
therefore closed the jaws; but finding that the left side still fell three 
lines below the right, I placed a pine wood wedge between the teeth 
on the right side, and drew the inferior maxilla up firmly. It now 
lacked only about half a line of being in place. 

There did not appear to be, after this, much difficulty in maintaining 
quiet and apposition of the fragments ; and I supposed, from, repeated 
examinations, that they were in exact line, until four weeks after the 
fracture had occurred, when I discovered that the central fragments 
were lifted about two lines above the lateral, and, also, slightly carried 
back; and although union had not taken place, yet they could not be 
replaced by any moderate force. The bones united with this slight 
deformity. Four days later no motion was perceptible, and the dis- 
placement seemed to be rather less. From. this time the dressings 
were discontinued. 

A gentleman, aged twenty-five years, had his inferior maxilla broken 
by the kick of a horse. The left lateral incisor was completely dis- 
placed, and a large piece of the dental arcade detached. 

Dr. S. Gr. Ellis, of Gowanda, N. Y., dressed the fracture, securing 
the loosened fragment by the main-spring of a watch, made fast to the 
teeth by a silver wire, and closing the mouth completely, without any 
interdental splint. Upon the outside he placed a pasteboard splint 
and bandages. On the fourth week a fragment exfoliated, and came 
out under the chin. The union was delayed some six or eight weeks. 

I examined the jaw ten years after it was broken, and -found the 
line of a vertical fracture exactly through the symphysis menti. The 
left half of the chin was slightly elevated, and the whole of that side 
of the shaft was smaller than the right. He could not close his teeth 
perfectly, yet he could close them sufficiently for the purposes of 
mastication. 

Stephen Smith, of New York, has seen two examples, 1 Lonsdale 
mentions three, 2 and Gibson has seen one. 3 

One ought not to be too confident, however, of the exact line of the 
fracture unless its existence can be demonstrated upon the naked bone, 
since a slight deviation to the one side or the other of the symphysis 
might n6t be easily detected in the living subject. 

Yelpeau, Fergusson, Gibson, Henry Smith and others, have re- 
marked that a separation at the symphysis takes place usually in in- 
fancy or childhood. But in the eight examples in which I find the 

1 New York Journ. Med., Jan. 1857, Hospital Reports. 

2 Practical Treatise on Fractures. By Edward P. Lonsdale. London, 1838, p. 226. 

3 Institutes and Practice of Surg. By Win. Gibson. Philadelphia, 1S41, p. 261. 



112 FRACTURES OF THE LOWER JAW. 

ages reported, only one, a case mentioned by Lonsdale, occurred in a 
person as young as ten years ; in one of the cases seen by myself the 
patient was seventeen years old, and the remainder have ranged from 
twenty-five years to sixty : and the average age of all is thirty-two 
years. 

I have seen one example of a fracture of the ramus, in a man twenty- 
three years old, who had been struck by a wooden block on the side 
of his face. The ramus was broken just above the angle, and the 
body was broken, also, obliquely near the symphysis. The intercepted 
fragment was carried inwards. 1 Ledran mentions the case of a child, 
ten or twelve years old, in whom the fracture was double also ; one 
fracture having taken place through the body, and one extending 
obliquely from the root of the coronoid process to the neck of the 
condyle. The intercepted fragment was, however, so little displaced 
that the fracture of the ramus was not discovered until after death. 2 
Malgaigne refers to this as the only example recorded ; but Stephen 
Smith, of the Bellevue Hospital, has met with it four times ; in one 
case the ramus was broken on both sides ; in two cases one ramus 
only was broken ; and in one the body was broken on the right side 
and the ramus on the left. 3 In two of these examples the fragments 
were not displaced. 

The coronoid process is so well protected by muscles and by the 
surrounding bony projections, that it is very rarely broken. 

Houzelot mentions a case in which a fall from a height produced 
at the same time a fracture of both condyles, of both coronoid pro- 
cesses, and of the symphysis. 4 

With this single exception, I am not able to find a recorded exam- 
ple of a fracture of this process. 

At least nine cases have been reported of fracture of the condyles, 
in all of which the separation occurred through the neck, viz., three 
by Ribes, two by Desault, one by BerardJ one by Houzelot, one by 
Bichat, one by Packard, of Philadelphia, and two by Watson, of N. Y. 
The fracture always occurring through the neck and just below the 
insertion of the external pterygoid muscle. 

According to Malgaigne, the analysis of these cases, excepting those 
mentioned by Packard and Watson, shows two classes of examples : 
the one occasioned by falls or blows upon the chin, and producing a 
simple fracture of the neck of the condyle ; the other occasioned by 
injuries inflicted upon the side of the face, and producing a fracture 
of the neck on the side corresponding to that upon which the injuries 
are received, and at the same time a fracture of the body upon the 
opposite side. These two varieties seem to be about equally common. 

In the case mentioned by Houzelot, and already cited, there existed 
at the same time a fracture of both condyles, of both coronoid pro- 
cesses and at the symphysis. The man also whom Watson saw in 

1 Trans. Amer. Med. Assoc. Report on "Deformities after Fractures," vol. viii. p. 
385, Case 17. 

2 Malgaigne, op. cit., p. 337, from Ledran, Observ. Chirur?., torn. i. obs. viii. 

3 New York Journ. of Med., Jan. 1857. Bellevue Hosp. Reports. 
* Malgaigne, op. cit., p. 400. 



FKACTUKES OF THE LOWER JAW. 113 

the New York Hospital, had fallen from the yard-arm of a vessel, 
breaking his thigh and arm bones and both condyles of the lower jaw. 
u His face was somewhat deformed by the retraction of the chin ; the 
mouth could not be opened so as to protrude the tongue to any great 
extent beyond the teeth, and the teeth of the upper and lower jaw 
could not be brought into contact. In attempting to move the jaw 
the patient experienced pain and crepitation just in front of the ears; 
the crepitation could easily be felt by placing the fingers over the 
fractured condyles. Nothing was done for the fractures of the jaw. 
In a few weeks the rubbing of the broken surfaces and attendant sore- 
ness ceased to trouble him ; but the shape of the jaw and difficulty of 
opening the mouth to any great extent, still remained unaltered." 1 

Etiology. — The causes, in such cases as I have myself investigated, 
seem generally to have been direct blows, in most instances inflicted 
by a club, or by the kick of a horse; in one instance the blow was 
inflicted by the fist. I have also seen a fracture immediately in front 
of the right cuspid, in a lad eight years of age produced by being 
pressed between two wagons, the pressure being made upon the two 
angles of the jaw. In ten of eleven cases mentioned by Stephen Smith, 
the causes were direct blows. Examples of fracture of the inferior 
maxilla from indirect blows have, however, been mentioned by other 
surgeons, the angles of the bone being pressed together by the pas- 
sage of a wheel, and the fracture taking place usually towards the 
symphysis. 

We have already alluded to the observation of Malgaigne, that frac- 
tures of the condyles belong to two classes : the one being occasioned 
by falls upon the chin, and the other by blows upon the side of the 
face ; the former acting as a counter force and the latter as a direct. 

The coronoid process can only be broken by a direct blow. 

Symptoms. — Fractures of the body of the bone are characterized by 
the usual signs of fracture elsewhere, namely, displacement, mobility, 
crepitus, and pain. 

The displacement is generally present; but its direction and amount 
vary according to the situation and course of the fracture, and also 
according to the violence and direction of the force producing the 
fracture. In one instance the displacement did not exist, and indeed 
I think it ought to be regarded as an example of a partial fracture. 

A lad, set. 9, was kicked by a horse on the 22d of June, 1858, the 
blow being received on the right side of the jaw. I saw him very 
soon after the accident, but could not detect any fracture, only the 
body of the jaw seemed to be bent in. On the third day, however, 
while endeavoring to straighten the jaw by violent pressure from 
within outwards I detected a feeble crepitus, which on more careful 
examination proved to be opposite the second incisor of the right 
side. I was also able to detect a slight motion at the same point. It 
was found impossible to rectify the bending, and no further efforts 
were employed. At this moment, after a lapse of nearly a year, the 
natural curve is partially but not completely restored. 

1 New York Journ. of Med., Oct. 1840. Hospital Reports. 






114 FRACTURES OF THE LOWER JAW. 

Leclran and other surgeons have also seen examples where neither 
the periosteum nor .mucous membrane was torn. 

Generally, in fractures of the body, the anterior fragment is de- 
pressed ; and Malgaigne affirms that where an overlapping occurs, the 
anterior fragment lies, generally, within the posterior; a fact which 
he explains by the direction which the line of fracture usually takes, 
namely, from without, inwards and backwards, as we have already 
mentioned. In one instance, reported by me to the Amer. Med. Assoc, 
where the jaw was broken at the symphysis and also on both sides 
through the body, the central fragments were found, after about four 
weeks, lifted two lines above the lateral fragments, and also slightly 
carried backwards. 1 I have twice also met with examples in which 
the posterior fragments were inclined to fall inwards toward the mouth, 
a circumstance which seemed to indicate that the course of the obliquity 
was in a direction opposite to that which Malgaigne has observed to 
be most frequent. In each of these examples the jaw was broken 
upon both sides, by blows inflicted with a club, and the fractures were 
situated well back. 2 It is possible, however, that the position of the 
fragments was clue rather to the direction and force of the impression 
than to the direction of the line of fracture. 

As to the action of the muscles in the production of displacement, 
Boyer, S. Cooper, Erichsen, and Malgaigne, have observed that their 
action upon the anterior fragment is greater in proportion as the frac- 
ture is nearer the sjnnphysis, and less in proportion as it approaches 
the angle. So that in the former case the attempt to close the mouth, 
is sometimes attended with a depression of the anterior fragment, 
causing a separation of the fragments at their alveolar margins; while 
in the latter case, the attempt to close the mouth forcibly is occasion- 
ally attended with separation of the fragments along the line of the 
base. 

While I am not prepared to deny the accuracy of these observations, 
it is proper to notice that Liston finds the greatest displacement when 
the fracture is opposite the first molar, and I must confess that the fact, 
as stated by Boyer and others, does not seem to admit of a satisfactory 
explanation; since the number, and consequently the power of the 
muscles which act upon the anterior fragment from below, is greater 
in proportion as the line of fracture is farther back. These muscles, 
namely, the digastricus, the genio-hyo-glossus, and the mylo-hyoideus, 
with several other muscles which act less directly, all tend to depress 
the anterior fragment, and in some slight degree to carry it backwards, 
a direction which, indeed, it usually takes, and which it would pro- 
bably always take if left alone to the action of the muscles. If the 
fracture has occurred through the angle, or at any point within the 
attachments of the masseter muscle, the action of those fibres of this 
muscle which remain connected with the anterior fragment will suffi- 
ciently explain the fact that it is not now so easily depressed below 
the level of the posterior fragment ; while the separation of the frag- 

1 Trans. Amer. Med. Assoc, vol. viii. p. 380, 1855, Case 6. 

2 Ibid., Cases 1 and 10. 



FRACTURES OF THE LOWER JAW. 115 

merits along the line of the base when an attempt is made to close 
the jaw forcibly, is probably due to the loosening and partial dislodg- 
ment of some of the molars, which, being, pressed upwards, act as a 
pivot upon which the fragments are made to bend. 

Boyer affirms, also, that "the fractured portions are never deranged 
so as that one passes on the other, or in the direction of their length ; 
for the action of none of the muscles of the lower jaw is parallel to 
the axis of that bone ; besides, its extremities are retained in the 
glenoidal cavities of the temporal bones." But this theory is too ex- 
clusive, since the fragments may have become displaced in any direc- 
tion independently of the muscular action. Moreover, the action of 
the muscles attached to the anterior fragment, although not parallel to 
the axis of the bone, does somewhat favor a displacement in this 
direction ; and the action of the pterygoid muscles upon the posterior 
fragment still farther favors this form of displacement. 

An overlapping of the fragments in the direction of the axis is, in 
simple fractures, no doubt, exceptional, and in such examples as I have 
seen, it was very trivial. It occurred in case " three" of my " Eeport," 
the fracture being near the mental foramen ; in case "two," the fracture 
being just anterior to the last molar; and also in case "six," where 
the bone had been broken through the centre of the body on both 
sides and through the symphysis; but in neither case did the over- 
lapping exceed two or three lines, and it was always easily overcome. 

The mobility of the fragments is not so striking in these accidents 
as in fractures of the long bones, yet it is generally sufficiently marked 
and especially where the bone is broken upon both sides at the same 
time. If only one side is broken, both motion and crepitus will be 
most easily detected by lateral pressure upon the posterior fragment, 
which, being the smallest and the least supported by antagonizing 
muscles, will be found to be the most movable. If the fracture is 
upon both sides, mobility and crepitus will be most readily developed 
by seizing upon the anterior fragment and moving it gently up and 
down, while the finger rests upon the alveolus within the mouth. 

Sometimes a slight swelling or tenderness at some point of the 
dental arcade, or the loosening or complete dislodgment of a tooth, 
will indicate the point of fracture. 

Pain, especially when the fragments are moved, is here more con- 
stant than in most other fractures, owing, perhaps, in part to the 
superficial position of the bone which renders the soft parts lying over 
it more liable to injury from the causes of fracture ; but also, in part, 
to the lesions which the inferior dental nerve may have suffered. It 
is, indeed, a matter of surprise that injury to this nerve does not 
oftener seriously complicate these accidents, coursing, as it does, 
through so large a portion of the angle and body of the bone. One 
might naturally suppose that its complete disruption would often 
occasion paralysis of those portions of the face to which it is finally 
distributed, and that its partial lesions and contusions would create, 
in many cases, the most acute and constant suffering. It is rare, how- 
ever, that we have present an amount of pain which might not be 
attributed to a severe shock, or a slight strain upon its fibres. I have 



116 FEACTUEES OF THE LOWER JAW. 

myself never seen any extraordinary suffering distinctly attributable 
to an injury of the dental nerve after fracture, nor any degree of facial 
paralysis. Rossi relates a case in which convulsion followed this 
accident, and in which, as a final remedy, he proposed to expose and 
bisect the nerve; and Flajani saw a patient whose jaw had been 
broken, die in convulsions on the tenth day, the muscular contractions 
having commenced as early as the fourth day after the accident. The 
autopsy disclosed a rupture of the dental nerve, but no injury to the 
braiu. 

These two examples are, as far as I know, all which our records 
supply, in which grave results have been attributed to lesions of this 
nerve ; and even here some doubt must remain whether the symptoms 
were not quite as much, due to the immediate injury done to the brain 
as to the nerve. 

Boyer explained the infrequency of severe injury to the dental 
nerve by the supposition that the " greater part of these fractures takes 
place between the symphysis and the foramen by which this nerve 
comes out." An opinion which may be correct, but needs confirma- 
tion. I have seen the body or angle broken at points posterior to the 
mental foramen, and where the nerve lies within its bony canal, twelve 
times, and in front of the mental foramen, eight times ; at other times 
the point of fracture has not been noted with such accuracy as to 
enable me to say whether it was in front of or behind the foramen. 

I suspect that a better explanation may be found in the fact that 
the fragments seldom overlap, to any appreciable extent, and that even 
the displacement in the direction of the diameters of the bone is gene- 
rally inconsiderable ; or if it does exist, the fragments are easily and 
promptly replaced. 

If the displacement is sufficient to occasion a complete disruption 
of the nerve, some degree of temporary paralysis in the portions of 
the face supplied by it must be inevitable ; and, perhaps, this occurs 
oftener than it has been noticed, since, during the confinement of the 
jaw by dressings, it is not likely to be observed, and after the lapse of 
a few weeks it will probably cease altogether. 

' Boyer remarks that when it is torn, " the square and triangular 
muscles of the chin are paralyzed. The skin of that part and the in- 
ternal membrane of the under lip preserve their sensibility, which it 
appears they owe to some threads of the portio dura of the seventh 
pair ; but the paralysis of these muscles does not prove of itself that 
the jaw is fractured." Boyer has, however, noticed this result but 
once, and then in a case where the bone was broken upon both sides 
and the soft parts greatly contused. The triangular and square mus- 
cles were paralyzed, in consequence of which there was a slight con- 
tortion of the mouth. A. Berard has also mentioned a case of vertical 
fracture occurring between the second and third molars, without 
displacement, which was accompanied with complete insensibility of 
the lip on the same side throughout the space comprised between the 
commissure and the median line, and between the free border of the 
lip and the chin. The paralysis disappeared after a few days. 1 

1 Malgaigne, from Gazette des Hopitaux, 10 Aout, 1841. 



FRACTURES OF THE LOWER JAW. 117 

To these signs now enumerated, we may add as occasional compli- 
cations, rather than as diagnostic symptoms, salivation, swelling of the 
submaxillary and sublingual glands, abscesses, necrosis, &c. If the 
blow has been vertical upon the chin, and the direction of its force 
has been towards the articulations, the bony structure of the ear, and 
even the brain may have suffered serious lesions, which may be indi- 
cated by a deafness, or a roaring in the ears, by bleeding from the 
external meatus, and by fatal coma. Tessier saw a man who had re- 
ceived the kick of a horse exactly upon the centre of the chin, break- 
ing the bone on both sides, and who, in consequence, bled freely from 
his ears ; x and Alix relates the case of a young man who, falling from 
a height and striking upon his chin, had broken his jaw. Insensibility 
immediately followed ; convulsions also ensued upon the fourth day, 
and he died upon the sixth. 2 

If the fracture is at the symphysis, it is generally vertical, and either 
fragment may be found slightly displaced upwards or downwards. 
In one of the examples seen by myself, the left fragment fell three 
lines below the right, and in another the right side had fallen about 
one line. In a case mentioned by Syme there was scarcely any dis- 
placement. 3 Liston remarks that it is usually slight. Erichsen and 
B. Cooper have observed the same. 

Signs which indicate a fracture through the angle have already 
been sufficiently considered when speaking of fractures of the body ; 
from which it only differs in the less degree of displacement, and in 
the fact that the posterior fragments are a little more prone to fall in- 
wards towards the mouth. I have noticed, also, that owing probably 
to the loosening and partial dislodgment of the last molar, it is some- 
times difficult to close the mouth, the same as in the fractures a little 
farther forwards. 

In the only example of fracture of the ascending ramus which I 
have seen, the bone being broken also through its body, the fracture 
of the ramus was easily recognized by both crepitus and mobility. 

As to the signs which indicate a fracture of the coronoid process, I 
am only able to infer them from its anatomical relations. There must 
be some embarrassment in the motions of the jaw, occasioned by the 
detachment of a portion of the fibres of the temporal muscle ; and it is 
probable that an examination by the finger within the mouth, would 
readily detect mobility and displacement. 

A fracture through the neck of the condyle is characterized by pain 
at the seat of fracture, especially recognized when an attempt is made 
to open or shut the mouth, by embarrassment in the motions of the 
jaw, by crepitus, which may usually be felt or heard by the patient 
himself, by mobility and displacement. 

The upper fragment, if disengaged from the lower, is drawn for- 
wards, upwards, and inwards, by the action of the pterygoideus exter- 
nus; and it is felt not to accompany the movements of the lower 
fragment. 

1 Malgaigne, pp. 383 and 386, from Jonrn. de Med., 1789, torn, lxxix. p. 246. 

2 Ibid., p. 386, from Alix, Observata Chir., fascie. 1, obs. 10. 

3 Amer. Journ. Med. Sci., vol. xviii. p. 243. 



V 



118 FKACTUKES OF THE LOWER JAW. 

The lower fragment is at the same time drawn upwards, in conse- 
quence of which the lower part of the face is distorted: a circumstance 
first noticed by Eibes, and which supplies an important diagnostic 
mark between a fracture of one condyle and a dislocation. In dis- 
location, the chin is commonly thrown to one side, but it is to the side 
opposite that on which the dislocation has occurred, while in fracture 
the chin is drawn to the same side. 

Prognosis. — Physick, of Philadelphia, saw a case of non-union of 
the body of this bone, which had existed nine months. 1 Dupuytren 
mentions a case which had existed three years. 2 Stephen Smith, of 
New York, reports a case of fracture of both the body and the ramus, 
in a man forty-five years old. The severity of the injury, with the 
supervention of delirium tremens, prevented the application of dress- 
ings until the thirteenth day. . On the twentieth day about a pint of 
blood was lost by hemorrhage from the seat of fracture. He remained 
in the hospital one hundred and thirty -seven days, and was finally dis- 
charged, the fragments not having yet united. 3 I have seen one 
example of fibrous union in the case of a man who broke the body of 
the jaw by a fall upon his chin. Malgaigne says that Boyer has seen 
several examples,, but I know of no other cases unless as the result 
of gunshot injuries which have been recorded. In no instance of a 
simple fracture which has come under my personal care, has the bone 
refused finally to unite, although I have seen the union delayed six, 
seven, ten, and even eleven weeks or more. 4 In three of these cases 
the fractures were either compound or comminuted ; but in one case 
the fracture was simple, the delay in the union being due to a feeble 
condition of the system, and in part, perhaps, to neglect of proper 
treatment. Since the commencement of the late war I have met with 
several examples of non-union, and of fibrous union after gunshot 
fractures: but so far as I can remember in all of these cases necrosis 
existed, or some portions of the bone had been carried away. 

The infrequenc}^ of non-union after this fracture, is a fact worthy of 
especial attention, because of the extreme difficulty, if not actual im- 
possibility, in many cases, of wholly preventing motion between the 
fragments, by any mode of dressing yet devised. Any one who has 
observed attentively, must have seen, not only that his dressings are 
more often found disturbed and loosened, than in the case of almost 
any other fracture, unless it be the clavicle, and thus the fragments 
have been through all the treatment subjected to frequent changes of 
position; but, also, that even while the dressings remain snugly in 
place, the patient seldom is able to perform the necessary acts of deg- 
lutition, or to speak, even, without inflicting some slight motion upon 
the fragments. 

Indeed, the rapidity as well as certainty with which this bone unites, 
has, I think, been observed by other surgeons, and I have myself 
noticed one instance, in an adult person, in which the bone was im- 
movable at the seat of fracture, on the seventeenth day, and, perhaps, 

1 Phila. Med. and Surg. Journ., vol. v. 2 Leqons Orales. 

3 Smith, New York Journ. of Med. and Surg., Jan. 1857. 

4 My Report on Deformities after Frac, Cases 2, 14, 15, 18. 



FRACTUEES OF THE LOWER JAW. 119 

earlier. In other instances, the union has been speedily effected after 
the removal of all dressings. 

The amount of deformity resulting, also, from these fractures is 
usually very trifling, whatever treatment has been adopted. Only 
eight of the united fractures, seen and recorded by me, are imperfect, 
and in none of these is the imperfection such as to be noticed in a 
casual examination of the face. The deformity which is usually found, 
is a slight irregularity of the teeth, produced, in most cases, by a fall- 
ing of the anterior fragment, but in one case by a slight elevation of 
the anterior fragment. But even this does not always interfere with 
mastication, and would often pass unnoticed by the patient himself. 
It is probable, too, that time, and the constant use of the lower jaw in 
mastication, will gradually effect a marked improvement in the ability 
to bring the opposing teeth into contact. I think I have observed 
chis in several instauces. 

Chelius remarks that in "double or oblique fractures it is very dif- 
ficult to keep the broken ends in their proper place; deformity and 
displacement of the natural position of the teeth commonly remain." 

In the second example of fracture through the symphysis mentioned 
by me, the left fragment remained slightly elevated, and the patient 
could not close his teeth perfectly, yet he could close them sufficiently 
for the purposes of mastication. It is probable, however, that ordi- 
narily no difficulty will be experienced in accomplishing a perfect 
cure when the separation has taken place only at the symphysis. 

In fractures of the condyles, more care is requisite to retain the frag- 
ments in apposition, and sometimes it may be found to be impossible. 
Eicherand mentions the case of a man, who, having been three months 
in the " Hopital de la Charite," for a double fracture of the lower jaw, 
one fracture being near the middle, and the other near the right con- 
dyle, left before the cure was complete. Seven or eight months after, 
he called upon Boyer, who extracted from a fistula in the meatus audi- 
torius externus, a bony mass which had evidently the form of the 
condyle. 1 Bichat mentions a similar case as having come under the 
observation of Desault ; 2 possibly it was the same which Boyer saw. 
Eibes says that a Parisian surgeon treated a double fracture of the jaw 
in a gentleman, one fracture being through the body, and the other 
through the neck of the condyle ; and in spite of the most assiduous 
and skilful attention, the patient recovered with a lateral distortion of 
the jaw, occasioned by the displacement of the fragments. 3 Ribes 
himself had to treat an accident of a similar character, and notwith- 
standing all his care, the result was the same as in the other example 
just cited. 4 Fountain, of Iowa, was much more fortunate, having 
made a complete and perfect cure. 5 

The proximity of this fracture to the articulating surface may occa- 
sion contraction of the ligaments about the joint; and a degree of 

1 Boyer, Lectures on Dis. of Bones, p. 53, Phila. ed., 1805. 

2 Desault, Treatise on Fractures and Luxations, Phila. ed., 1805, p. 3. 

3 Malgaigne, op. cit., p. 402. 

4 Ibid., p. 402. 

5 Fountain, New York Jour. Med., Jan. 1860. 



120 FRACTURES OF THE LOWER JAW. 

embarrassment to toe motions of the jaw "has followed in the expe- 
rience of Desault and others, even when the cure has been most com- 
plete ; but this has usually remained only for a short period. 

Sanson asserts that when the coronoid process is broken, the frac- 
ture never unites; but that mastication is performed very well, the 
masseter and pterygoid muscles then fulfilling the office of the tem- 
poral. 1 

Treatment. — The few attempts which I have made to restore a com- 
pletely dislocated tooth to its socket, or to retain it in place when very 
much loosened, have generally resulted in its removal at some later 
day, and especially where the fracture has been near the angle and a 
molar has been disturbed. I believe it would be better practice 
always to remove the molars under these circumstances, unless they 
remain attached to the alveoli, and cannot be removed without bring- 
ing them away also ; and this, whether the loosened teeth are situated 
in the line of fracture or not. It is seldom that they can be made 
again to occupy their sockets perfectly, and where the teeth are in the 
line of the fracture, the attempt to restore them to place will sometimes 
prevent the proper adjustment of the fragments. In cases, also, in 
which the teeth farther forwards are completely dislodged at the seat 
of fracture, it is scarcely worth while to replace them. 

As to those teeth whose loosened condition is due only to a splitting 
of the alveoli in a longitudinal direction, the same rule will not always 
apply. Sometimes, after a careful readjustment, the fragments will 
reunite, and the teeth remain firm. 

If the bone is chipped off upon the outside, through or near the 
line of the sockets, the teeth may not be always much disturbed, and 
the loss of the fragments may be of less consequence, nor have I gene- 
rally succeeded in saving them ; yet if they remain adherent to the 
soft parts, it is proper to make the attempt. 

The expedients to which surgeons have resorted for the purpose of 
retaining in place the fragments, when the bone is broken through its 
body, may be arranged under the names of ligatures, splints, bandages, 
and slings. 

The ligature has been applied both to the teeth and to the bone 
itself. Thus, in an oblique fracture near the angle, where the frag- 
ments could not otherwise be prevented from falling inwards, Baudens 
passed a strong ligature, formed of thread, around the fragments and 
in immediate contact with them, tying the ligature over the teeth 
within the mouth. Ko accident followed, and on the twenty-third 
day, when he removed the ligature, the bone had united firmly and 
smoothly. 2 

In the case of the fracture of the inferior maxilla, reported by Dr. 
Buck, to the New York Pathological Society, and already referred to, 
the bone " was broken between the two incisor teeth of the left side : 
the part of the bone on the left of the fracture was driven in, and 
interlocked behind the end of the right portion, so as to be separated 

1 S. Cooper's First Lines. Amer. ed., 1844. vol. ii. p. 311. 

2 Malgaigue, op. cit., p. 398. 



FRACTURES OF THE LOWER JAW. 121 

by a fingers breadth. Finding it impossible otherwise to reduce the 
fracture, Dr. B. dissected off the under lip, so as to expose the fracture. 
He found that the right anterior portion of the fractured bone ter- 
minated in an angular projection as far as on a line below the left 
angle of the mouth. The lip was then divided to the chin, and the 
soft parts holding the fragments together incised. A chisel was then 
insinuated behind the projecting angle of the bone, while it was being 
excised by the metacarpal saw. When the bone was restored to its 
natural position, it was found so apt to become displaced, that holes 
were drilled at the lower angle of the fracture, and adjustment main- 
tained by wiring them together, the wire passing out through the 
lower angle of the wound. Sutures and adhesive straps, with a band- 
age, were employed to maintain the adjustment of the parts. So far 
the patient has done well, being supported by liquid nourishment 
introduced through a tube passed through the space left by one of 
the incisors, which, on account of its looseness, was removed." 1 Dr. 
E. A. Kinloch, of Charleston, S. C, has reported a similar case, in 
which he employed successfully the wire. 2 

In May, 1858, while trephining at the angle of the jaw for the pur- 
pose of cutting out a portion of the dental nerve in a patient suffering 
from neuralgia, I accidentally broke the jaw in two at the point at 
which the trephine was applied. I immediately bored a hole in the 
opposite extremities of the two fragments, and fastened them together 
with a silver wire, by which I was able to maintain complete appo- 
sition, and in three weeks the union was accomplished, the wire sepa- 
rating and falling out of itself. No splints were ever used. 3 

With these exceptions, so far as I am aware, the ligature has been 
employed as a means of retention, only by fastening it upon the teeth, 
either upon those which are situated on the opposite sides of the frac- 
ture, or upon others a little more remote, or upon the corresponding 
teeth of the upper jaw, or upon the teeth on the opposite sides of the 
same jaw. 

Ordinarily the ligature, composed of either fine gold, platinum, or 
silver wire, or of firm silk or linen threads — (Celsus advised the use 
of horsehair) — has been applied to the two teeth on the opposite sides 
of the fracture, or if these have not been sufficiently firm, to the next 
teeth. This practice, recommended first by Hippocrates,, has received 
the occasional sanction of Ryff) Walner, Chelius, Lizars, Erichsen, 
Miller, B. Cooper, Skey, and others, but by Boyer, Gibson, and Mal- 
gaigne, it has been reprobated. 

Dr. S. Gr. Ellis, of Gowanda, N. Y., as we have already seen, has 
treated a fracture, occurring through the symphysis, in an adult, by 
placing the mainspring of a watch within the dental arcade, and 
securing it in place with silver wire. The mouth was kept closed by 
bandages carried under the chin. The fragments united with only a 
slight vertical displacement. 4 

1 New York Journ. of Med., &c, March, 1847, p. 211. 

2 Kinloch, Am. Journ. Med. Sci., July, 1859, p. 67. 

3 Buffalo Med. Journ., vol. xiv. p. 148. 

4 Trans. Amer. Med. Assoc. My report on " Defor.," &c, vol. viii. p 3SS, Case 14. 

Q 



122 FRACTURES OF THE LOWER JAW. 

Dr. George Hay ward, of Boston, surgeon to the Massachusetts 
General Hospital, says: "When the bone is not comminuted and there 
are teeth on each side of the fracture, the ends of the bone can be 
kept in exact apposition by passing a silver wire or strong thread 
around these teeth and tying it tightly. In several cases of fracture 
of the jaw, in which the bone was broken in one place only, I have, in 
the course of the last few years, adopted this practice with entire suc- 
cess, and without the aid of any other means. It will be found very 
useful, also, as an auxiliary, in more severe cases, in which it may be 
required to use splints and bandages, or to insert a piece of cork 
between the jaws, as recommended by Delpech. It requires some 
mechanical dexterity to apply the thread neatly; but in large cities 
we can avail ourselves of the skill of dentists for this purpose." 1 I 
have myself in two or three instances used a linen thread with 
excellent results. 

Guillaume de Salicet advises to secure with a silk thread, at the 
same moment, the teeth belonging to the two fragments, and the cor- 
responding teeth of the upper jaw; 2 while the dentist Lemaire, being 
applied to by Dupuytren to secure in place the ununited fragments of 
a broken jaw, fastened the two left canine teeth to each other by a 
wire of platinum, as had been already suggested by Guillaume de 
Salicet ; to these he added two other modes of ligature which were 
altogether original. One wire, made fast to the last molar upon one 
side, traversed the mouth and was secured to one of the bicuspids 
upon the opposite side ; the other was stretched from the first inferior 
bicuspid on the right to the first superior bicuspid on the left. A 
cure was accomplished at the end of two months, but one of the wires 
had nearly bisected the tongue ; and as it had gradually become im- 
bedded, the flesh had closed over it until it rested like a seton through 
the middle of the tongue. 3 

None of these various methods recommend, themselves very satis- 
factorily to the practical surgeon ; for besides that they are all of them, 
in a large majority of cases, wholly unnecessary, and in other cases, 
owing to the absence of the teeth, or to their loosened or decayed 
condition, or to the closeness with which they are set against each 
other, absolutely impossible, it must be seen, also, that they will 
generally prove feeble and inefficient. The wires act only upon the 
upper extremity of the line of fracture, leaving its lower portions 
liable to be disturbed by trivial causes ; they tend gradually to loosen 
even the firm teeth which they embrace, and not unfrequently, after 
having been made fast with much labor, they soon become disarranged 
or break. They require, therefore, almost always the additional pro- 
tection afforded by bandages, interdental splints, &c. AloDe they are 
usually insufficient, and if properly constructed bandages, slings, in- 
terdental splints, &c., are employed, they are not needed. Sometimes, 
moreover, they are actually mischievous, as when they loosen a sound 

i Boston Med. and Surg. Journ., vol. xix. p. 133, 1838, 

2 Malgaigne. op. cit., p. 392. 

3 Journ. Univer. des Sci. Med., torn. xix. p. 77. 



FRACTURES OF THE LOWER JAW. 123 

tooth or press upon and inflame the gums. A. Berard passed a silver 
wire twice around the necks of two adjoining teeth on the opposite 
sides of a fracture. It retained the fragments perfectly in apposition 
during several days ; but soon the gums swelled and became painful ; 
the teeth loosened, and it was found necessary to remove the wire. 
Chassaignac sought to avoid these evils by placing the wire upon the 
middle of the crown, free from the gums, and by including four teeth 
instead of two. A waxed linen thread was made fast in this manner, 
in a case of simple fracture, on the seventh day. On the following 
morning the thread was found broken. He applied then a silk liga- 
ture in the same manner. On about the third day this also was dis- 
arranged; the ligatures were now discontinued until the eighteenth 
day, when he renewed the experiment with a piece of gold wire. 
Fourteen days after this the ligature remained firm, but the gums 
were red and bleeding. The patient not having again returned to 
Chassaignac, the result is not known. 1 

As to the method suggested by Guillaume de Salicet, it presents no 
advantages to compensate for its inconveniences ; while that actually 
practised by the dentist Lemaire, successful indeed, threatened to sub- 
stitute a loss of the tongue for an ununited fracture of the jaw. 

Splints have been employed in various ways. First, simple inter- 
dental splints, laid along the crowns of the teeth and only sufficiently 
grooved to be easily retained in place ; Second, clasps, which are ap- 
plied over the crowns and sides of the teeth, operating chiefly by their 
lateral pressure, or made fast by screws ; Third, splints applied to the 
outer and inferior margin of the jaw ; Fourth, interdental splints com- 
bined with outside splints. 

Interdental splints have been recommended by many surgeons from 
an early day, and they continue to be employed occasionally up to 
this moment. 

Boyer advises the use of cork splints placed one on each side be- 
tween the upper and lower jaws, in a few exceptional cases. Miller 
recommends the same in all cases, the " two edges of cork sloping 
gently backwards, with their upper and under surfaces grooved for 
the reception of the upper and lower teeth." Fergusson also has 
usually adopted the same practice. Muys and Bertrandi employed 
ivory wedges. 2 

On the other hand they are rejected entirely by Syme, Chelius, Skey, 
Erichsen, and Gibson. 

The objections which have been stated to their use are : that they 
are unsteady and become easily loosened and disarranged ; that they 
occasionally press painfully upon the inside of the cheeks; that they 
accumulate about themselves an offensive sordes, and finally that they 
are unnecessary, since experience has proven, says Gibson, that " there 
is always sufficient space between the teeth to enable the patient to 
imbibe broth or any other thin fluid placed between the teeth." 

It is not strictly true, however, that in all cases there will be found 

1 Lond. Med. and Phys. Journ., Nov. 1822, p. 401. 

2 Loud. Med.-Chir. Rev., vol. xx. p. 470. 



124: FEACTUEES OF THE LOWEB JAW". 

sufficient space between the teeth, when the mouth is closed, for the 
imbibition of nutrient fluids. I have myself seen exceptions, and in 
such a case the patient, if the mouth were closed in the usual way, 
would have to be fed through a tube conveyed along the nostrils into 
the stomach, as suggested by both Samuel and Bransby Cooper in 
certain bad compound fractures, or through an opening made by the 
extraction of one of the front teeth : neither of which methods ought 
to be preferred to the interdental splints ; but then the separation of 
the front teeth for the purpose of receiving food, is by no means the 
only object to be gained by their use, nor indeed the principal object. 
Their great purpose is to act as splints whenever the absence of teeth 
either in the upper or lower jaw renders the two corresponding arcades 
unequal and irregular, and prevents our making use of the upper as 
a kind of internal splint for the lower jaw. 

It is with a view to the accomplishment of this important end that 
they are often valuable, and ought sometimes to be considered as in- 
dispensable. I believe, also, that many of the inconveniences which 
have been found to attend the use of cork or wood, are obviated by 
the substitution of gutta percha in the manner which I recommended 
to the profession in 1849, l and also again in my report to the Ameri- 
can Medical Association, made in the year 1855. I have employed 
this method repeatedly myself, and my suggestions have been followed 
by Stephen Smith, of the Bellevue Hospital, Xew York, and by many 
others with, as they affirm, the most satisfactory results. Dr. Smith 
declares indeed that nothing can surpass it in efficiency. 

The mode of preparing gutta percha, and of adapting it between 
the teeth, is as follows : Dip a couple of pieces of the gum, of a 
proper size, into hot water, and when they are softened, mould them 
into wedge-shaped blocks, and carry them to their appropriate places 
between the back teeth on each side of the mouth; taking care, of 
course, that on the fractured side the splint extends sufficiently far 
forward to traverse thoroughly the line of fracture. Now press up 
each horizontal ramus of the jaw until the mouth is sufficiently closed, 
and the line of the inferior margin is straight ; in this position retain 
the fragments a few minutes, until the gum has well hardened. Mean- 
time, it will be practicable, generally, to introduce the fingers into the 
mouth, and to press the gutta percha laterally on each side towards 
the teeth, and thus to make its position more secure. When it is 
hardened, remove the splints for the purpose of determining more 
precisely that they are properly shaped and fitted. 

It is scarcely necessary to say that in carrying the long wedge- 
shaped block into the mouth, the apex of the wedge is to be intro- 
duced first. 

The superiority of this splint is now at once perceived. If properly 
made, it is smooth upon its surface, and not, therefore, so liable to 
irritate the mouth as wood or cork, and it is so moulded to the teeth 
that it will never become displaced. It possesses this advantage, also, 
that in case more or less of the teeth are gone in either the upper or 

1 Buffalo Med. and Surg. Journ., vol. v. p. 144, Aug. 1849. 



FRACTURES OF THE LOWER JAW. 125 

lower jaw, it fills up the vacancies, and renders the support uniform 
and steady. 

The " clasp," applied over the crowns and sides of the teeth, is not 
intended to act as an interdental splint; but by its lateral pressure it 
is expected to hold the fragments in apposition upon nearly the same 
principle with the ligature. 

Mutter, of Philadelphia, and N. K. Smith, of Baltimore, employ for 
this purpose a plate of silver, folded snugly over the tops and sides 
of two or more teeth adjacent to the fracture. 

Nicole, of Nuremburg, employed for the same purpose a couple of 
steel plates fitted accurately along the anterior and posterior dental 
curvatures, secured in place by a steel clasp, the clasp being furnished 
with a thumb-screw, in order the more effectually to accomplish the 
lateral pressure. 

Malgaigne has extended the idea of Nicole, by substituting for the 
two steel plates, a single plate composed of flexible and ductile iron, 
which is fitted accurately to all the irregularities of the posterior 
dental arch. From the two extremities of this plate, and from two 
other intermediate points, four small steel shafts arise perpendicularly, 
cross the crowns of the teeth at right angles, and then fall down again 
perpendicularly upon the anterior dental arcade. Each steel shaft 
being furnished with a thumb-screw, the iron plate can now be made to 
bear against the teeth so as to form a posterior dental splint. The 
teeth are also protected in front against the direct action of the thumb- 
screw by the interposition of a leaden plate. 

J. B. (running, Dentist, of New York, has substituted for all these 
materials vulcanized India rubber, which he employs both as a clasp 
and as an interdental splint ; and according to Dr. Covey 1 the same 
material has been used with excellent results by J. B. Beans, Dentist, 
of Atlanta, Ga. The following is Dr. Beans' plan of procedure. 

An impression is taken in wax of the crowns of the teeth of the 
uninjured jaw, and of each fragment separately of the broken jaw. 
When, in doing this, the ordinary " impression cup" used by dentists 
cannot be introduced, one composed of a thin metallic plate, which 
is covered with wax and stiffened by a rim of wire, may be substituted. 

" From these impressions are made casts of plaster of Paris, very 
carefully prepared, so as to produce a smooth, hard surface, and giving 
as perfect a representation of the teeth as possible. These plaster 
models are then adjusted, properly antagonized in their normal posi- 
tion, and placed in the l maxillary articulator.' 

" The fragments of the model representing the broken jaw are held 
in their proper position by wax, being secured thus one to the other, 
and to the remaining plate of the articulator." * * * The model jaws 
are now opened from three to five lines, and a wax model of a splint is 
built up between the molars, covering also the inner and outer surfaces 
of the teeth. A connecting band of wax is laid from one side to the 
other behind the upper front teeth, leaving thus an opening in front 
for the reception of the food. This wax and plaster model now com- 

1 Beans, Richmond Med. Journ., Feb. 1866. 



126 



FRACTURES OF THE LOWER JAW. 




Maxillary Articulation. 

1, 1. Upper and lower plates. 

2, 2. Adjustable rods. 

3, 3. Adjustable hinge. 



Fig. 27. 



posing one piece, is then removed from the articulator, and placed in 
a dentist's "flask," and a complete mould of the model is again formed 

from plaster laid on in sections, 
Fi s- 26 - in a manner which those accus- 

tomed to make plaster moulds 
will readily understand. The 
plaster having fairly set, the flask 
and mould are opened, the wax 
carefully removed, and the spaces 
thus left in the mould at once 
filled with the rubber rendered 
soft by heat. The mould is again 
closed, replaced in the flask, and 
by heat the rubber is thoroughly 
vulcanized. The flask is again 
opened, the plaster removed, and 
an interdental splint of rubber 
remains, which is fitted accurately to all the surfaces of the teeth both 
above and below. 

The splint is now placed in the mouth, adjusted to the teeth and 
the lower jaw secured in position by the apparatus represented in the 
accompanying wood cut. 

Dr. Covey says, that during the late war Dr. Beans was placed in 

charge of a hospital at Macon, Geor- 
gia, devoted exclusively to the re- 
ception of this class of injuries, and 
that over forty cases were treated, 
and with eminent success. 

My own judgment of this appara- 
tus is, that so far as the substitution 
of vulcanized rubber for gutta percha 
is.concerned, it is wholly unnecessary 
in the great majority of simple frac- 
tures of the jaw. Gutta percha is 
applied with great facility, and with 
equal accuracy to all the dental sur- 
faces, and it speedily hardens suffi- 
ciently for all practical purposes. 

In gunshot fractures, however, and 
in certain other badly comminuted 
fractures, I can well understand how 
the surgeon may advantageously avail 
himself of vulcanized rubber, which being somewhat harder, may be 
made to grasp the teeth attached to the several fragments more 
firmly; and indeed ma}^, in a few cases, allow of the teeth being made 
fast to the splint by screws. 

It will be observed that these are the cases which Dr. Beans has had 
chiefly under treatment. 

An examination of the cases reported by Dr. Covey, will also show 
that the apparatus was never applied earlier than the tenth day, even 




apparatus for broken jaw, applied. 



FEACTUKES OF THE LOWER JAW. 127 

when the patients were under the charge of Dr. Beans from the first, 
and that in most cases the application of the apparatus was delayed 
to a much later period. Indeed it is apparent that there may be the 
same reasons for occasional delay in the application of vulcanized rub- 
ber, as in the application of gutta percha, or any other mode of sup- 
port and dressing. 

In reference to the head apparatus, or sling, as used by Dr. Beans, 
we have only a single remark to make. It is a modification of the 
apparatus employed for many years by myself — the modification con- 
sisting in the use of a horizontal piece of wood supporting a cup 
which is placed under the chin, the purpose of which is to prevent 
the lateral pressure usually made by the maxillary bands. The 
necessity of this modification has long been recognized by myself and 
others in certain fractures ; and it is especially important in all com- 
minuted and gunshot fractures. To the attainment of this purpose, 
namely, the prevention of lateral pressure, I have employed usually a 
firm gutta-percha splint under the chin, to the projecting lateral ex- 
tremities of which the maxillary bands have been attached ; and I 
think it much better than Dr. Beans' piece of wood. In a great 
majority of cases, however, occurring in civil practice, that is to say, 
in most simple fractures, this submental splint is unnecessary, since 
the lateral pressure is harmless, especially when the interdental splints 
of gutta percha or of vulcanized rubber are employed. 

In short, while I am prepared to admit that Dr. Beans has by his 
appareil and by the application of great mechanical skill, talent, and 
industry, treated successfully many cases which by other appliances 
and in other hands- might have resulted most unfortunately, yet it is 
plain that his method will find its field of usefulness in civil practice 
limited to exceptional cases. 

Dr. J. S. Prout, of Brooklyn, New York, has suggested to me a very 
ingenious mode of employing the interdental splint and wire ligature 
conjointly, and which method, at my request, he adopted recently in 
a case under my care at Bellevue Hospital. A plate of gutta percha 
was placed upon the top of the -teeth across the line of fracture, and 
this was secured in position by silver wire, which had been made to 
grasp firmly the crowns of the adjacent teeth and was then brought 
over the horizontal gutta percha plate. In this case it accomplished 
all that was desired. 

External splints, applied along the base or outside of the jaw, were 
first recommended by Pare, who used for this purpose leather ; and 
they have been employed in some form, occasionally, by most surgeons. 
Generally they have been composed of flexible materials, such as 
wetted pasteboard, first recommended by Heister, felt, linen saturated 
with the whites of eggs, paste, dextrine or starch ; plaster of Paris has 
also been used : and they have been retained in place by either band- 
ages or the sling. As before stated, I have myself used for this purpose, 
gutta percha, but I shall speak of it as one form of the sling dressing. 

Undoubtedly useful, and even necessary in some cases, especially 
where there exists a great tendency to a vertical displacement, they 
will be found, also, in many cases, to render no essential service, and 
may properly enough be dispensed with. 



128 FKACTUKES OF THE LOTVEE JAW. 

Whatever objections hold to the use of metallic clasps, must apply 
equally to the use of those forms of apparatus in which it is attempted 
to secure the fragments by means of a combination of these clasps with 
outside splints, and in which it is proposed to dispense with all band- 
ages or slings, the mouth being permitted to open and close freely 
during the whole treatment. Motion of the jaw cannot be permitted 
in any case where the fracture is far back, since it is then impossible 
to grasp the posterior fragment between the two parallel splints. 
Nothing bat complete immobility of the jaw will now insure immo- 
bility to the fracture. They are liable, moreover, to additional objec- 
tions, which will be readily suggested by an explanation of their mode 
of construction. 

Chopart and Desault originated this idea as early as 1780, for frac- 
tures occurring upon both sides ; in which cases they advised " band- 
ages composed of crotchets of iron or of steel, placed over the teeth, 
upon the alveolar margin, covered with cork or with plates of lead, 
and fastened by thumb-screws to a plate of sheet iron, or to some 
other material under the jaw." 

The apparatus invented by Eutenick, a German surgeon, in 1799, 
and improved by Kluge, is thus described by Dr. Chester: "It con- 
sists, 1st, of small silver grooves, varying in size according as they 
are to be placed on the incisors or molars, and long enough to extend 
over the crowns of four teeth ; 2d, of a small piece of board, adapted 
to the lower surface of the jaw, and in shape resembling a horseshoe, 
having at its two horns, two holes on each side ; 3d, of steel hooks of 
various sizes, each having at one extremity an arch for the reception 
of the lower lip, and another smaller for securing it over the silver 
channels on the teeth, and at the other end a screw to pass through the 
horseshoe splint, and to be secured to it by a nut and a horizontal 
branch at its lower surface ; 4th, of a cap or silk nightcap to remain 
on the head ; and 5th, of a compress corresponding in shape and size 
with the splint. The net or cap having been placed on the head and 
the two straps fastened to it on each side, one immediately in front of 
the ear and the other about three inehes farther back, which are to 
retain the splint in its position by passing through the two holes in 
each horn ; a silver channel is placed on the four teeth nearest to the 
fracture, on this the small arch of the hook is placed, and the screw 
end having been passed through a hole in the splint, is screwed firmly 
to it by the nut, after a compress has been placed between the splint 
and the integuments below the jaw. 

" If there is a double fracture, two channels and two hooks must of 
course be used." 1 

Bush invented a similar apparatus in 1822, 2 and Houzelot in 1826 ; 
since which the apparatus has been variously modified by Jousset, 
Lonsdale, Malgaigne, and perhaps others. 

Lonsdale says he has employed his instrument in numerous cases 

1 London Med.-Chir. Rev., vol. xx. p. 471, from Monthly Archives of the Medical 
Sciences, 1834. 

2 Malgaigne, op. cit., p. 395. 



FRACTURES OF THE LOWER JAW. 129 

and with complete success. 1 Eutenick succeeded with his apparatus 
in a case where the displacement persisted in spite of all other means. 2 
Jousset was also successful in two cases. 1 Wales, Asst. Surg. U. S. 
Navy, succeeded with an instrument of his own invention. 4 

But others have not been equally fortunate ; or if they have suc- 
ceeded in holding the fragments in apposition, and in securing a bony 
union, other serious accidents have followed. 

In the first case mentioned by Houzelot, the instrument was kept 
on thirteen days, after which an attack of epilepsy deranged every- 
thing, and the patient was transferred to Bicetre. The second patient 
complained immediately of an intense pain under the chin and a pro- 
fuse salivation followed. These symptoms were subdued by the sixth 
day, but, for some reason, the apparatus was finally removed on the 
tenth day. The fragments hereafter showed no tendency to derange- 
ment. Seven days after its removal, an abscess, which had formed 
under the chin, was opened. In the third case the apparatus was left 
in place thirty days, and an abscess formed also under the chin. Neu- 
court applied it in a double fracture where the central fragment was 
much displaced. The apposition was well preserved, but he was 
obliged to remove it on the seventeenth day on account of a phlegmon 
which was forming under the chin. The patient to whom Bush ap- 
plied his apparatus, would wear it but a few days. Malgaigne had 
the same experience with Bush's apparatus. 

In addition to the pain and inflammation, followed by submaxil- 
lary abscesses, which have been such frequent results of its use, 
Malgaigne has noticed that it is exceedingly inclined to slide forwards 
and become displaced. 

In short, notwithstanding the unqualified testimony of Lonsdale in 
favor of this method of treatment, especially in fractures at the sym- 
physis, and in fractures through any portion of the shaft anterior to 
the masseter muscle, it is, in my judgment, sufficiently plain that it is 
applicable to only a very limited number of cases, and I am not cer- 
tain but that it would be better to reject it altogether ; and I should 
scarcely have thought it worth while to notice these modes of treat- 
ment at all were it not for the respectability of the gentlemen who 
have given them their countenance, and perhaps to show how fruitful 
and exhaustless in resources is the genius of our profession. 

The treatment of fractures of the inferior maxilla by a single-headed 
bandage or roller, numbers among its distinguished advocates the 
names of Gibson and Barton; indeed, I think the practice is at the 
present time peculiar to a few American surgeons. Gibson gives the 
following directions for applying his roller : " A cotton or linen com- 
press, of moderate thickness, reaching from the angle of the jaw nearly 
to the chin, is placed beneath and held by an assistant, while the sur- 
geon takes a roller, four or five yards long, an inch and a-half wide, 
and passes it by several successive turns under the jaw, up along the 

1 Lonsdale: Practical Treatise on Fractures ; London, 1838, p. 234. 

2 Malgaigne, op. cit., p. 396. 3 ibid., p. 396. 
4 Wales, Am. Journ. Med. Sci., Oct. 1860. 



130 



FRACTURES OF THE LOWER JAW. 




Gibson's bandage for a fractured jaw. 



sides of tlie face and over the head; now changing the course of 

the bandage, he causes it to pass off at 
Fi S- 28 - a right angle from the perpendicular 

cast, and to encircle the temple, occiput 
and forehead, horizontally, by several 
turns ; finally, to render the whole more 
secure, several additional horizontal 
turns are made around the back of the 
neck, under the ear, along the base of the 
jaw, under the point of the chin. To 
prevent the roller from slipping or chang- 
ing its position, a short piece may be 
secured by a pin to the horizontal turn 
that encircles the forehead, and passed 
backwards along the centre of the head 
as far as the neck, where it must be 
tacked to the lower horizontal turn — 
taking care to fix one or more pins at 
every point at which the roller has crossed." 

Barton emploj^s, also, a compress, and a roller five yards long; the 
application of which is thus described by Sargent : Place the initial 

extremity of the roller upon the occiput, just 
Flg * 29# below its protuberance, and conduct the 

cylinder obliquely over the centre of the left 
parietal bone to the top of the head ; thence 
descend across the right temple and the zy- 
gomatic arch, and pass beneath the chin to 
the left side of the face; mount over the left 
zygoma and temple to the summit of the 
cranium, and regain the starting point at the 
occiput by traversing obliquely the right 
parietal bone ; next wind around the base of 
the lower jaw on the left side to the chin, 
and thence return to the occiput along the 
right side of the maxilla; repeat the same 
course, step by step, until the roller is spent, 
and then confine its terminal end. 
These bandages possess the advantages of being easily obtained, 
of simplicity and facility of application, and in general, we may add, 
of complete adaptation to the ends proposed. The only objections to 
their use which I have ever noticed, are occasional disarrangements, 
and the tendency, as in all other continuous rollers, to draw the frag- 
ments to one side or the other, according as the successive turns of the 
bandage are carried to the right or left. There is one other objection, 
having reference to the occasional inadequacy of this dressing to pre- 
vent an overlapping of the fragments ; to which objection also the 
sling, as usually constructed, is equally obnoxious, and of which I 
shall speak presently. 

Finally, it is to the sling, in some of its-various forms, with or with- 




Barton's bandage for a 
fractured jaw. 



FEACTUKES OF THE LOWER JAW. 



131 



Fig. 30. 




Four-tailed bandage or sling, for the lower jaw. 



out the interdental splint, that surgeons have generally given the prefer- 
ence. The sliDg is known, also, by 
the name of the four-headed or the 
four-tailed roller or bandage. 

B. Bell, Boyer, Skey, S. Cooper, 
B. Cooper, Syme, Fergusson, Mayor, 
Lizars, and Chelius, employ the sling 
usually ; and the favorite mode is to 
use for this purpose a piece of muslin 
cloth about one yard long and four 
inches wide, torn down from its two 
extremities to within about three or 
four inches of the centre. Others 
have used leather, gutta percha, ad- 
hesive straps, gum-elastic, etc. 

Where the muslin is used, it is 
quite customary to lay against the 
skin a piece of pasteboard, wetted, 
and moulded to the chin, or simply 
a soft compress; and some choose to 
open the centre of the bandage suffi- 
ciently to receive the chin. The middle of this bandage being laid 
upon the chin, the two ends corresponding to the upper margin of the 
roller are now carried across the front of the chin, behind the nape of 
the neck, and made fast; while the two lower heads are brought 
directly upwards from under the sides of the chin, along the sides of 
the face, in front of the ears, and made fast upon the top of the head. 
The dressing is completed by a short counter-band extending across 
the top of the head from one bandage to the other; or the several 
bands may be made fast to a nightcap, in which case the counter-band 
will be unnecessary. 

It only remains for me to describe my own method of dressing these 
fractures with the sling. 

Having frequently noticed the tendeney of the sling, as ordinarily 
constructed, and of Gibson's roller, to carry the anterior fragment 
backwards, especially in double fracture where the body of the bone 
is broken upon both sides, I devised, some years since, an apparatus 
intended to obviate this objection, and which I have used now many 
times with complete success. 

It is composed of a firm leather strap, called maxillary, which, 
passing perpendicularly upwards from under the chin, is made to 
buckle upon the top of the head, at a point near the situation of the 
anterior fontanelle. This strap is supported by two counter-straps, 
made of strong linen webbing, called, respectively, the occipito-frontal 
and the vertical. The occipito-frontal is looped upon the maxillary 
at a point a little above the ears, and may be elevated or depressed 
at pleasure. The occipital portion of the strap is then carried back- 
wards and buckled under the occiput, while the frontal portion is 
buckled across the forehead. The vertical strap unites the occipital 
to the maxillary across the top of the head, and prevents the upper 



132 



FKACTUEES OF THE LOWER JAW. 



Fie. 31. 




The author's apparatus. 



part ol the latter from becoming displaced forwards. At each point 

where a buckle is used, a pad must 
be placed between the strap and the 
head. 

The maxillary strap is narrow 
under the chin to avoid pressure 
upon the front of the neck, but im- 
mediately becomes wider so as to 
cover the sides of the inferior maxilla 
and face, after which it gradually di- 
minishes to accommodate the buckle 
upon the top of the head. The an- 
terior margin of this band, at the 
point corresponding to the symphy- 
sis menti, and for about two inches 
on each side, is supplied with thread 
holes, for the purpose of attaching 
a piece of linen which, when the ap- 
paratus is in place, shall cross in 
front of the chin, and prevent the 
maxillary strap from sliding back- 
wards against the front of the neck. 
The advantage of this dressing over any which I have yet seen, 
consists in its capability to lift the anterior fragment almost vertically, 
and at the same time it is in no danger of falling forwards and down- 
wards upon the forehead. If, as in the case of most other dressings, 
the occipital stay had its attachment opposite to the chin, its effect 
would be to draw the central fragment backwards. By using a firm 
piece of leather, as a maxillary band, and attaching the occipital stay 
above the ears, this difficulty is completely obviated. 

Having removed such teeth as are much loosened at the point of 
fracture, and replaced those which are loosened at other points, unless 
it be far back in the mouth, and adjusted the fragments accurately, 
the lower jaw is to be closed completely upon the upper, and the 
apparatus snugly applied. It is not necessary in most cases to buckle 
the straps with great firmness, since experience has shown that a 
sufficient degreee of immobility is usually obtained when the apparatus 
is only moderately tight. 

If the integuments are bruised and tender, a compress made of two 
or more thicknesses of patent lint should be placed underneath the 
chin, between it and the leather. 

If the inability to introduce nourishment between the teeth when 
the mouth is closed, or the irregularity of the dental arcade renders 
the use of interdental splints necessary, gutta percha, as I have already 
explained, ought, in general, to be preferred to any other material. 

The patient must be forbidden to talk, or laugh, and when he lies 
down his head should rest upon its back, for whatever mode of dress- 
ing is employed, and however carefully it is applied, it will be found 
that a slight motion and displacement will occur whenever the weight 
of the head rests upon the side of the face. 



FRACTURES OF THE LOWER JAW. 133 

Occasionally, indeed, as often as every two or three days, the appa- 
ratus may be loosened or removed, only taking care generally not to 
disturb the interdental splints, when they are used, and to support the 
jaw with the hand, during its removal ; and, at the same time, the face 
may be sponged off with warm water and castile soap. It should not 
be left off entirely, however, in less than three or four weeks, even 
where the fracture is most simple, nor ought the patient to be allowed 
to eat meat in less than four or five weeks. 

To cleanse the mouth and prevent offensive accumulations, it should 
be washed several times a day with a solution of tincture of myrrh, 
prepared by adding one drachm to about four ounces of water. 

The same apparatus, and without any essential modification, is ap- 
plicable to fractures of the symphysis and of the angle of the inferior 
maxilla, as well as to fractures of the body of the bone. 

Instead of the leather, I have in a few instances, especially of com- 
pound fractures where it became necessary to allow the pus to dis- 
charge externally, used a sling or a splint composed of gutta percha, 
suspended by bands carried over the top of the head. The piece 
from which this splint is made should be two or three lines in thick- 
ness, covered with cloth, and padded under the chin. It will be found 
convenient to cover it with cloth before immersing it in the hot water. 
The water should be nearly at a boiling temperature, so that the splint 
may become perfectly pliable ; and it should be laid upon the face 
and allowed to mould itself while the patient lies upon his back. 

Having thus fitted it accurately to the face, it may be removed and 
openings made at points corresponding with the wounds upon the 
skin, before it is reapplied. 

As has been already explained, the gutta percha, if sufficiently thick, 
and if the lateral wings are allowed to project a little on either side, 
will serve effectually to protect the sides of the face against pressure 
from the bandage ; and being more easily moulded to the base and 
front of the chin than any other material which has yet been employed, 
must have the preference. The necessity for its use, however, is only 
occasional. 

In fractures of either condyle, unaccompanied with displacement, 
the simple leather or muslin sling will sometimes accomplish a perfect 
and speedy cure, as the two cases reported by Desault will sufficiently 
demonstrate. But if the fragments have become separated, the re- 
placement is difficult, and the retention uncertain. 

Eibes was the first to suggest and to practice a very ingenious 
method of reduction in these cases. Having seen two examples which 
had resulted in deformity under the usual treatment, which consisted 
in simply pressing forwards the angle of the jaw, it occurred to him 
that while the upper or condyloidean fragment was not acted upon at 
the same moment by pressure from the opposite direction, a reduction 
must be impossible. The case of a cannonier whose jaw was broken 
through the neck of the condyle on the right side, and through its 
body on the left, afforded him an opportunity to determine the prac- 
ticability of a method of which he had as yet only conceived the idea. 
Malgaigne thus describes his procedure : " With the left hand seize the 



134: FEACTUEES OF THE HYOID BOXE. 

anterior portion of the jaw, for the purpose of drawing it horizontally 
forwards, while you carry the index finger of the right hand to the 
lateral and superior part of the pharynx. You will meet at first the 
projection formed by the styloid process, but moving your finger for- 
wards you will find soon the posterior border of the ramus of the jaw ; 
and following this border from below upwards, you will arrive at the 
inner side of the condyle, which you will push outwards in such a 
manner as to engage it upon the other fragment. This manoeuvre 
cannot be made without causing nausea, as the finger always does 
when carried into the posterior part of the pharynx; but this is a 
slight inconvenience. The redaction obtained, bear the jaw upwards 
and backwards in order to press and fix the condyle between it and 
the glenoid cavity, then fasten it in place with a sling." The frag- 
ments were thus easily brought into apposition in the case reported 
by Eibes, and the patient was cured without any deformity. 

In addition to these means, the angle of the jaw ought to be pressed 
permanently forwards by means of a compress placed between it and 
the mastoid process, and held in place by a suitable bandage ; or we 
may adopt the method which proved so successful with Fountain, 
namely, wire the front teeth of the lower jaw to the front teeth of the 
upper in such a manner as to draw the chin forwards and thus 
maintain apposition. 

If the coronoid process be alone broken, it is sufficient to close the 
mouth with any form of sling or bandage which may be most con- 
venient. 



CHAPTEE XIII. 

FRACTURES OF THE HYOID BONE. 

M. Oefila has reported the case of a man, aged sixty -two years, who 
had been hanged, and whose os hyoides was broken through its body 
on its right side. 1 M. Cazauvieilh has also seen a fracture of this 
bone in two persons who had been hanged : in one of which the 
fracture was probably in the body of the bone, and in the other 
through one of its cornua. 2 

Lalesque published in the Journal ITehdomadaire, for March, 1833, a 
case which occurred in a marine, sixty-seven years old, " who, in a 
quarrel, had his throat violently clenched by the hand of a vigorous 
adversary. At the moment there was very acute pain, and the sensa- 
tion of a solid body breaking. The pain was aggravated by every 
effort to speak, to swallow, or to move the tongue, and when this 
organ was pushed backwards, deglutition was impossible. The patient 

1 Traite de Med. legale, troisieme ed., torn. ii. p. 423. 

2 Cazauvieilh, du Suicide, etc., p. 221. 



FEACTUKES OF THE HYOID BONE. 135 

could not articulate distinctly ; and he was unable to open his mouth 
without exciting a great deal of pain. He placed his hand upon the 
anterior and superior part of his neck to point out the seat of the 
injury. This part was slightly swollen, and presented on each side 
small ecchymoses, one above, more decided, immediately under the left 
angle of the lower jaw. " The large cornua of the os hyoides was very 
distinctly to the right side," and it could be felt on the left deeply seated 
by pressing with the fingers ; in following it in front toward the body 
of the bone, a very sensible inequality near the point of junction of 
these two parts could be perceived. By putting the finger within the 
mouth, the same projections and cavities inverted could be felt, and 
even the points of the bone which had pierced the mucous membrane, 
&c, were evident. Having bled the patient, and placed a plug between 
his teeth to keep the mouth open, the broken branch was brought by 
the finger back to the surface of the body of the bone, and easily re- 
duced. The position of the head inclined a little back ; rest, absolute 
silence, diet, and some saturnine fomentations, composed the after- 
treatment. To avoid a new dislocation by the efforts of swallowing, 
the oesophagus tube of Desault was introduced, to conduct the drinks 
and liquid aliments into the stomach ; this sound was allowed to re- 
main until the twenty-fifth day ; at this time the patient could swallow 
without pain, and began to take a little more solid nourishment, and 
at the end of two months the cure was complete. By placing a finger 
within his mouth, a slight nodosity could be felt in the place where, 
in the recent fracture, the splintered points were perceptible. 1 

Dieffenbach has also recorded a fracture of the great right horn, pro- 
duced in the same manner, by grasping the throat between the thumb 
and fingers, which occurred in a girl only nineteen years old. Yery 
slight pressure upon the side of the bone was sufficient to move the 
fragment inwards, and to produce a crepitus, but it immediately 
resumed its place when the pressure was removed. There being, 
therefore, no displacement, the cure was effected in a short time 
without resort to any remedies except tisans and antiphlogistics. She 
was not even forbidden to speak. 2 

Auberge saw a similar case, in a person fifty-five years old, occasioned 
by grasping the throat. The fracture was in the great horn of the right 
side, and the displacement was so complete that crepitus could not be 
felt, and the mucous membrane of the pharynx was penetrated by the 
broken bone. 3 

The following example is reported by Dr. Wood, of Cincinnati, 
Ohio, as having come under his observation in the year 1855 : — 

"Through the kindness of our friend Dr. P. Gr. Fore, of this city, 
we were invited to examine a case of fracture of the os hyoides, that 
had occurred about one week before we saw it, in one of his patients. 
The patient was a female, about thirty years of age, who had fallen 
down the cellar steps, striking the prominent parts of the larynx and 

1 Amer. Journ. Med. Sci., vol. xiii. p. 250. 

2 Medic. Vereinszeitrmg fur Preussen, 1833, No. 3 ; Gazette Med., 1834, p. 187. 

3 Revue Med., July, 1835. 



136 FKACTUKES OF THE HYOID BONE. 

hyoid bone against a projecting brick, severely injuring the larynx as 
well as fracturing the bone. 

"The fracture was on the left side, and near the junction of the 
great horn with the body of the bone. Crepitus was distinctly felt 
on pressing the bone between the thumb and finger ; or when the pa- 
tient would swallow ; though, at this time, the severe symptoms that 
followed the accident, and continued for several days, had somewhat 
subsided. 

" Immediately after the accident there was profuse bleeding from 
the fauces, and she experienced great difficulty and pain in the act of 
swallowing, and the power of speech was almost entirely lost. On 
attempting to depress or protrude the tongue, she felt distressing 
symptoms of suffocation. Considerable inflammation and swelling of 
the throat and larynx ensued, and continued in some degree up to the 
time of our visit. 

" To-day (about four weeks since the accident) Dr. F. informs us 
that the patient has so far recovered as to be able to converse, though 
the voice is somewhat impaired. She is yet unable to swallow solid 
food, and is wholy sustained by fluids." 1 

Marcinkovsky saw a woman in whom both the lower jaw and the 
left horn of the os hyoides were broken by a fall from her carriage 
against a wall. She died in about twenty-four hours from suffocation. 2 

Dr. Grriinder reports the following : — 

" A laborer, set. 63, fell from a wagon on his face, and discharged 
a large quantity of blood by the mouth. He found he could not swal- 
low, and when seen twelve hours afterward, complained of severe pain 
in the neck and nape, with inability to turn his head, though no in- 
jury of the vertebras could be detected. His voice was hoarse and 
difficult. On attempting to drink, the fluid was rejected with violent 
coughing, the patient declaring he felt it as if entering the air-passages. 
An examination of the fauces led to no explanation of this condition. 
The epiglottis did not, however, appear to completely close the larynx, 
or to be in its exact position. The tongue was movable in all direc- 
tions, and pressing it down with a spatula caused no inconvenience. 
The hyoid seemed to possess its continuity. No crepitation or abnor- 
mal movability could be perceived, and no pain at the root of the tongue 
occurred on attempting to swallow. After repeated examinations, the 
case was concluded to be one in which the functions of the nervus 
vagus had undergone great disturbance, or the muscles of the larynx 
had become torn or paralyzed. Medicine and food were administered 
by means of an elastic tube. The patient had a good appetite and 
slept well; the pain of the neck was lost, and its motion recovered; a 
hectic cough, from which he had long suffered, alone remaining. After 
continuing, however, to go on thus well for six days, the cough in- 
creased ; the appetite failed; strength was lost; the voice was scarcely 
audible ; and in five more days the patient died exhausted. At the 
autopsy a fracture of the os hyoides was found. One of the large 

1 Western Lancet; also N. Y. Journ. Med., vol. xv. p. 152. 

2 Medic. Vereinszeitung, fur Preussen, 1833, No. 15 ; Gazette Medicale, 1833, p. 354. 



FRACTURES OF THE HYOID BONE. 137 

cornua was broken, and had become firmly imbedded, between the 
epiglottis and rima glottidis, inducing the raised position of the epi- 
glottis, loss of voice, and difficulty in swallowing. The fracture was 
probably produced by muscular action, a cause first assigned in a case 
occurring to Ollivier d' Angers." 1 I think it more probable, however, 
that this fracture was the result of a direct blow, than of muscular 
action. 

In the case referred to, however, as having been reported by Olli- 
vier, there can be no doubt that the fracture was due to muscular 
action alone. 

A woman, fifty-six years old, made a misstep and fell backwards, 
and at the same moment that her head was thrown violently back, she 
felt distinctly a sensation as if a solid body had broken, in the upper 
part of her neck and upon its left side. An examination showed that 
she had fractured the great left horn of the os hyoides. Inflammation 
and suppuration followed, and finally, after about three months, the 
posterior fragment made its way out in a condition of necrosis, and 
the fistula promptly healed, but there remained for many years a sense 
of uneasiness about these parts when she swallowed, sometimes amount- 
ing to pain. 2 

Etiology. — Of the ten cases which I have found upon record, three 
were produced by hanging ; three by grasping the throat between the 
thumb and fingers ; three by direct blows, or by falls upon the front 
of the neck ; and one by muscular action alone. 

The observation of Mr. South that fracture of the bone " is almost 
invariably found" 3 in persons executed by hanging, is probably incor- 
rect, since although a large proportion of these subjects are submitted 
to dissection both in this and other countries, yet I know of but these 
three examples which have been published. 

Pathology, Symptomatology, and Diagnosis. — The body of the bone 
seems to have been broken in all of those cases which resulted from 
hanging : while in all of the other examples the fracture has occurred 
in one of the great horns, or at the junction of the horns with the 
body. Generally the displacement inwards of one of the fragments 
has been so complete that crepitus could not be detected. It was pre- 
sent, however, in the examples mentioned by Dieffenbach and Wood. In 
two instances the mucous membrane has been penetrated, and in one 
the fragment was projected between the epiglottis and rima glottidis. 

The accident has been characterized by a sudden sensation as if a 
bone had broken ; in a few instances, by profuse bleeding from the 
fauces ; by difficulty in opening the mouth ; by impossibility of deglu- 
tition, and by loss of voice in others ; with great pain in moving the 
tongue, the pain being especially at its root ; in one instance the 
tongue was perceptibly drawn to one side. There is also usually more 
or less swelling and soreness about the neck, with ecchymosis \ and at 

1 Schmidt's Jahrbuch., vol. lxviii. ; also Amer. Journ. Med. Sci., vol. xlix. p. 253, 
Jan. 1852. 

2 Malg.,.op. cit., p. 405. 

3 Note to Chelius' Surgery, Amer. ed., vol. i. p. 581. 

10 



16$ FEACTUEES OF THE HYOID BONE. 

a later period, cough, expectoration, hoarseness, &c. The circum- 
stances which, however, indicate certainly the nature of the accident, 
are preternatural mobility of the fragments, with or without crepitus, 
and the angular, inward projection, which may in most cases be dis- 
tinctly felt in a careful examination of the pharynx. 

In the case related by Griiner, the only symptoms were a loss of 
voice, difficulty of deglutition, and a sensation, when the attempt was 
made to swallow, as if the fluids passed into the windpipe ; with also 
an imperfect closure of the epiglottis upon the rima glottidis. No 
preternatural mobility or irregularity in the fragments could be de- 
tected, nor was there crepitus, and it was concluded that the bone was 
not broken, yet the autopsy showed that the fragment was imbedded 
deeply between the epiglottis and the rima glottidis. 

Prognosis. — It is only in view of its complications that this accident 
can be regarded as serious ; where the severity of the injury has been 
such as to fracture the lower jaw at the same time, as in the case re- 
lated by Marcinkovsky, or such as to bury the fragment deep in the 
tissues about the rima glottidis as in the case mentioned by Griiner, a 
favorable termination could scarcely have been expected ; and these 
are the only cases yet published in which the death was in any way 
connected with the fracture. One half of the whole number have died, 
but of these, three have died by hanging, and the remaining two from 
the causes named. Of the three in which the accident resulted from a 
direct blow, only the patient of Dr. Fore, of Cincinnati, has survived ; 
while of the three whose fractures resulted from lateral pressure upon 
the cornua, all recovered ; so, also, did the patient in whom the frac- 
ture was produced by muscular action. 

Treatment. — No doubt when the fragments are displaced an attempt 
ought to be made to replace them by introducing one finger into the 
mouth, while with the opposite hand the fragments are supported from 
without. Lalesque found this a matter of some difficulty, but Auberge 
experienced no difficulty at all. I suspect, however, that the amount 
of difficulty will very much depend upon the degree of displacement, 
and the consequent lacerations of the soft tissues about the bone. But 
however this may be, it must be altogether another thing to be able to 
keep in exact apposition the broken ends of a bone whose diameter is 
so inconsiderable and upon which it is quite impossible to apply any 
apparatus or dressings to retain the fragments in place. Lalesque 
threw the head of his patient slightly back, with the view of making 
"permanent extension" upon the fragments through the action of the 
muscles and ligaments attached to the bone, and he recommends this 
position as that which is best calculated to preserve the coaptation. 
Malgaigne, on the contrary, without having himself seen any example 
of this fracture, believes that the position of flexion of the neck, with 
entire relaxation of the muscles, would be most suitable. 

In all cases it will be proper to enjoin silence, and to adopt suitable 
.measures to combat inflammation; such as general or topical bleeding, 
fomentations, moistening the mouth with cool water, or permitting 
small pieces of ice to rest in the mouth until dissolved, without in 
general allowing the fluid to be swallowed ; but in some examples, no 
doubt the patient may be permitted to swallow. 



FEACTUEE OF THE CARTILAGES OF THE LARYNX. 139 



CHAPTEE XIV. 

FRACTURE OF THE CARTILAGES OF THE LARYNX. 
§ 1. Thyroid Cartilage. 

The examples of fracture of the larynx which may be found upon 
record, are also very few. M. Ladoz examined the larynx of a man 
who had been assassinated, and upon whose neck he found a hand- 
kerchief bound so tightly as to leave, after its removal, a deep furrow; 
but the neck showed also distinct marks produced by the fingers and 
thumb. There was a fracture of the thyroid cartilage which extended 
obliquely downwards and outwards through its right wing. The whole 
of the larynx was very much ossified, although the subject was only 
thirty-seven years old. 1 

In 1823, M. Ollivier communicated to the Academy of Medicine a 
case in which, this cartilage being broken, the patient died of suffoca- 
tion. 2 

M. Marjolin says, "Two women at the hospital being engaged in a 
quarrel, one of them seized her antagonist by the throat, and griped 
her so strongly that she broke the thyroid cartilage from its upper to 
its lower margin. You will imagine that it was not very difficult to 
determine the existence of a fracture, and that no retentive apparatus 
was demanded. * Silence, regimen, a small bleeding, and the cure was 
accomplished." 3 

Habicot operated successfully, in 1620, by introducing a leaden 
tube into the trachea in a case in which the thyroid was " damaged." 
Gibb, Norris, Nelaton, and Kenderline, have each reported examples 
of fracture of this cartilage alone. 4 

§ 2. Thyroid and Cricoid Cartilages. 

Plenck saw a fracture of both the thyroid and cricoid cartilages pro- 
duced by falling upon the rim of a pail. 5 Morgagni also says that he 
had seen fractures of the larynx; and Remer mentions a fracture of 
the larynx found in a person who had been hanged ; 6 but in neither 
case is it said in which cartilage the fracture occurred, or whether it 
had not occurred in both. 

1 Gazette Medicale, 1838, p. 698. 

2 Archives Generates de Medecine, tome ii. p. 307. 

3 Marjolin, Cours de Patholog. Chir., p. 396. 

4 Hunt, Frac. of Larynx, &c. Am. Journ. Med. Soi., April, 1866. 

5 Malg., op. cit., p. 409. 

6 Morgagni, de Sedibus, etc.,Epist. 19, num. 13,14, etl6 ; Remer. Annates d'hygiene, 
tome iv. p. 171 ; from Malg. 



140 FRACTURE OF THE CARTILAGES OF THE LARYNX. 

Dr. O'Brian, of Edinburgh, reports in vol. xviii. of the Edinburgh Med. 
and Surg. Journ., a case of fracture of both cartilages, involving the 
trachea also, in a woman who had received a kick under the jaw, and 
who died on the following day. Hunt has collected other cases, some 
of which involved the arytenoid cartilages, the hyoid bone, the trachea, 
&c. 

I am able to furnish, from my own observation, another example 
of fracture of both the thyroid and cricoid cartilages: — 

John Calkins, of Collins, Erie Co., N. Y., set. 41, is supposed to have 
been kicked by a young horse on the 10th of Nov. 1856. He was 
alone in the stables when the accident occurred, and being stunned 
by the blow, he could not himself give any account of the manner in 
which the injury was received. "When found he was sitting upright, 
but unable to articulate except in a whisper. Drs. Barber and Davis, 
of Colden, saw him about two hours after. His countenance was 
anxious ; his pulse feeble ; extremities cold ; and he was breathing 
with great difficulty. A small quantity of blood was issuing from his 
fauces. His upper lip was cut, and a few of his teeth dislocated ; the 
wound appearing as if inflicted by one of the corks of the horse's shoes. 
There was no other wound ; but over the left wing of the thyroid car- 
tilage there was a slight discoloration, pressure upon which produced 
intense pain and suffocation, and disclosed the fact that the thyroid 
prominence was depressed very much and broken. Cold lotions were 
directed to be applied, and as the thirst was excessive, but deglutition 
impossible, he was permitted to hold pieces of ice in his mouth. This 
plan, with but slight modifications, such as the substitution of warm 
fomentations to the neck for the cold lotions, was continued until the 
following evening, when, at the request of the attending physician, Dr. 
Barber, I was called to see him. The symptoms remained nearly the 
same as at first. He was unable to speak audibly, or perform the 
act of deglutition ; his breathiDg was difficult, and at times threatened 
suffocation. The lateness of the hour, with other circumstances, deter- 
mined me to defer surgical interference until morning. At daybreak 
of the 12th I made the operation of laryngotomy, and introduced a 
large double canula into the crico-thyroidean space. This operation 
was rendered difficult by the great amount of swelling about the neck, 
due both to emphysema, and bloody with serous infiltrations. The 
breathing immediately became easy, and gradually the appearance of 
asphyxia disappeared from his face; but after about six or seven 
hours, he began perceptibly to fail in strength, and died at 3 o'clock 
P. M., of the following day, apparently from exhaustion rather than 
from suffocation: having survived the accident about seventy-two 
hours, and the operation about thirty-four hours. 

The autopsy disclosed a comminuted fracture of the thyroid carti- 
lage with a simple fracture of the cricoid. The thyroid was broken 
almost perpendicularly through the centre ; the line of fracture being 
irregular, and inclining slightly to the left side. The left inferior horn 
was broken off about three lines from its articulation with the cricoid 
cartilage. The right ala was broken also in a line nearly vertical, but 
irregular, at a point about six lines from its posterior margin. The 



CRICOID CARTILAGE. 141 

pomum Adami was depressed to the level of the cricoid cartilage, and 
the left ala, being completely detached, was thrown inwards and up- 
wards several lines. Underneath the perichondrium, especially upon 
the inner side, there was pretty extensive bloody infiltration. Ossifi- 
cation of the cartilages had commenced at several points, but it had 
made but little progress. The central fracture of the thyroid was 
through cartilage alone. The fracture of the right ala was through 
cartilage until it reached a bony belt comprising the two inferior lines 
of its course. The left lower horn was ossified, and the fracture was 
through this bony structure. The fracture through the cricoid carti- 
lage commenced close upon the margin of a bony plate, but in its 
whole course it traversed only cartilage. It was on the left side. 
There was also an incomplete fracture on the right ala of the thyroid 
cartilage, commencing in the line of the principal fracture and ex- 
tending obliquely downwards about three lines, until it was arrested 
by the bony plate which constituted the lower margin of this wing. 

A ragged, lacerated wound in the back of the larynx, above the 
cricoid cartilages, communicated directly with the oesophagus. 



§ 3. Cricoid Cartilage. 

Both Valsalva and Cazauvieilh have each met with a single exam- 
ple of this fracture, without fracture of the thyroid cartilage; and 
Weiss has found the cricoid cartilage broken into numerous frag- 
ments, and at the same time separated from the trachea. 1 

General Etiology of Fractures of the Laryngeal Carti- 
lages. — As a predisposing cause, advanced age, with its usual con- 
comitant, partial or complete ossification of the cartilages, has been 
thought to occupy a prominent place. In the case reported by Plenck, 
the cartilages were already very much ossified, although the subject 
was only thirty-seven years old. Morgagni observed that in his 
experience it had occurred always in advanced life. In my own 
case, however, the cartilages were only slightly ossified, the patient 
being forty-one years old ; nor did the lines of the several fractures 
indicate a preference for the bony plates; but it seems to me that they 
rather avoided them, and in the case of the incomplete fracture, the 
bone appeared to have arrested the fracture. In fact, a few experi- 
ments have satisfied me that the adult laryngeal cartilages are quite 
as brittle as bone, and, consequently, that ossification in no way in- 
creases their liability to fracture. 

Hunt ascertained the age in fifteen cases, and but one of the whole 
number was over 45 years ; five occurred in children, one of whom 
was only four years old. 

The immediate causes have been direct blows, as falling upon the 
edge of a pail, a kick from a horse, or pressure, as in hanging, or in 
grasping the larynx strongly between the thumb and fingers. 

1 Malg., op. cit., p. 408. 



142 FRACTURE OF THE CARTILAGES OF THE LARYNX. 

General Symptomatology, etc. — The signs of this accident are 
such as may attend any severe injury of this organ, whether accom- 
panied with a fracture or not, such as pain, swelling, difficult degluti- 
tion, embarrassed respiration, loss of voice, cough, and perhaps bloody 
expectoration, with emphysema, &c. 

But none of these can be regarded as diagnostic ; although, when 
taken in connection with the history of the accident, especially if a 
very severe and direct blow has been received, or more certainly still 
when symptoms so grave and complicated have followed an attempt 
at strangulation by grasping the throat, they may be regarded as pro- 
bable or presumptive evidences. 

A positive diagnosis must depend upon the presence of a sensible 
displacement, or motion of the fragments, with crepitus. 

In the case related by Plenck, death followed almost immediately, 
with convulsions, and without any outcry ; indicating, probably, some 
severe lesion of the spinal marrow ; while in M. Ollivier's patient suffo- 
cation ensued, at first intermittent, and finally permanent. 

In my own case, suffocation was throughout a prominent symptom, 
with only such slight intervals of amelioration as might have been 
occasioned by the extrication of the blood or mucus from the larynx. 

General Prognosis. — The prognosis ought to depend rather upon 
the complications and upon the gravity of the symptoms, than upon 
the simple decision of the question of fracture. A fracture produced 
by grasping the wings of the thyroid cartilage, and without any great 
contusion or laceration of the soft parts, might reasonably be expected 
to terminate favorably under judicious management ; but when, on the 
contrary, the fracture is the result of great violence inflicted directly 
upon the front of the cartilages, producing severe contusion and lace- 
ration, and is followed by great swelling, emphysema, very difficult 
respiration, complete aphonia, impossibility of deglutition, &c, the 
prognosis cannot but be unfavorable. 

General Treatment. — In examples of simple, uncomplicated frac- 
ture, " silence, regimen, and a small bleeding" may suffice; but in other 
cases, it may become necessary to introduce a tube into the stomach 
to supply the patient with food and drinks, since deglutition may be 
impossible. If, also, suffocation is imminent, there may remain no 
alternative but a resort to tracheotomy or to laryngotomy. 

Indeed, one of these operations ought, we think, to be resorted to in 
all cases in which emphysema is prominent. Dr. William Hunt, of 
the Pennsylvania Hospital, in his excellent paper on " Fractures of the 
Larynx and Euptures of the Trachea," in which he has arranged a 
tabular synopsis of twenty-nine cases, says that of twenty-seven cases 
ten recovered and seventeen died. Of eight cases in which tracheo- 
tomy was performed, but two died. In the four cases in which recovery 
took place without an operation no mention is made of bloody expec- 
toration or of emphysema. 1 

1 Hunt, Airier. Journ. Med. Sci., April, 1866. 



FRACTURES OF THE VERTEBRAE. 143 

As to a " reduction" of the fragments by manipulation, I believe it 
will be found generally, if not always, impracticable. Whatever dis- 
placement exists must be mostly inwards, and we can have no means 
of forcing them again outwards. Nor, if once replaced, do I see any 
reason to suppose that they would not become immediately displaced. 

Chelius has suggested the propriety, in such cases, of cutting open 
the coverings of the larynx freely in the median line, and after stanch- 
ing the bleeding, proceeding at once to divide the larynx itself in its 
whole length and then replacing the broken cartilages. 1 The pro- 
cedure has an aspect of severity, but I can well conceive of circum- 
stances which would justify its adoption ; not, however, so much for 
the purpose of replacing the cartilages, as for the purpose of arresting 
a fatal internal hemorrhage, and of giving a free admission of air to 
the lungs. If this operation were to be practised, the wound ought 
to be left open for a sufficient length of time to allow of the subsidence 
of the inflammation, and then permitted to close with such precautions 
as experience teaches are usually necessary after the windpipe has 
been opened. 

Active antiphlogistic measures, combined with fomentations to the 
neck, so far as these latter are found to be agreeable and practicable, 
are important measures, and not to be overlooked in the general plan 
of treatment; 

My own patient, also, found small pieces of ice, permitted slowly to 
dissolve in the mouth, very grateful; but he preferred very much, as 
an external application, the warm fomentations to the cold lotions. 



CHAPTER XY. 

FRACTURES OF THE YERTEBRJE. 

It will be convenient to divide fractures of the vertebrae into frac- 
tures of the spinous processes, transverse processes, vertebral arches 
and bodies. 

§ 1. Fracture of the Spinous Processes. 

Fractures of the spinous apophyses, independent of a fracture of the 
arches, may occur at any point of the vertebral column; and they may 
be occasioned by a blow received upon either side of the spinal column ; 
or by a force directed from above or from below. 

Symptoms and Pathology. — These accidents may be recognized by 
the lively pain at the point of fracture, produced especially when the 
patient bends forwards, which position renders the skin and muscles 
tense and drives the fragments into the flesh; by the swelling, ten- 

1 System of Surgery, Philadelphia ed., vol. i. p. 5S1, 1847. 




144 FRACTURES OF THE VERTEBRAE. 

derness and discoloration ; but chiefly by the lateral displacement of 
the broken process, and the mobility. 

Duverney met with a fracture of two of the processes in the same 
person, and which could only be recognized by the mobility, since, 

as the autopsy proved, there was no dis- 
Fig. 32. placement. Nor would it be surprising 

if the displacement was absent in a ma- 
jority of these accidents, inasmuch as the 
attachment of the ligaments from above 
and below with the strong and short 
muscles upon either side, must prevent 
a deviation in any direction until these 
tissues were more or less torn. Sir Astley 
mentions a case in which, however, such 
lacerations did occur, and the lateral de- 
formity was quite conspicuous. 

A boy had been endeavoring to sup- 
port a heavy weight upon his shoulders, 
when he fell, bent double. Immediately 
Fracture of the spinous process. he had the appearance of one suffering 

under a distortion of the spine of long 
standing. Three or four of the processes were broken off and the 
corresponding muscles were detached so as to allow the processes to 
fall off to the opposite side. There was no paralysis, and he was 
soon discharged with the free use of his limbs, but the deformity 
remained. 1 

If the fragment is thrown directly downwards, as it possibly may 
be, especially in the cervical or lumbar region, yet not without a rap- 
ture of the supra-spinous ligaments, or of the ligamentum nuchae, then 
the displacement will be more difficult to detect, and it may require 
some more care not to confound it with a fracture of the vertebral arch 
or of the plates from which the spinous processes arise. The process 
not being felt in its natural position, nor upon either side, it may seem 
to have been forced directly forwards, when in fact it is only thrown 
downwards towards its fellow. The danger of error in the diagnosis 
will be increased when to these conditions are added paralysis of those 
portions of the body which are below the seat of the fracture, and 
which, in this case, may be the result of an extravasation of blood or 
of simply a concussion of the spinal marrow. Nor do I think it would 
be possible now to determine positively whether it was simply a frac- 
ture of a spinous process of the arch, or of the body itself of the ver- 
tebra. In case, however, the paralysis results from concussion, the 
fact will in most cases soon become apparent by a return of sensation 
and of the power of motion. 

Prognosis. — Hippocrates affirmed that here, as in fractures of other 
spongy bones, the union took place speedily. It is quite probable 
that this venerable father of surgery has stated the fact correctly, and 
yet in the only example known to me where the condition of this 

1 Sir Astley Cooper, op. cit., p. 459. 



FRACTURES OF THE TRANSVERSE PROCESS. 145 

process, as proved by dissection, has been carefully stated, the frag- 
ment had not united by bone at all. This is the case related by Sir 
Astley as having been examined by Mr. Key. A subject was brought 
into the dissecting room in which one of the processes had been broken, 
and, on dissection, a complete articulation was found between the 
broken surfaces, which surfaces had become covered with a thin layer 
of cartilage. The false articulation was surrounded with synovial 
membrane and capsular ligaments, and contained a fluid like synovia. 1 

Ordinarily the displacement continues, whatever treatment may be 
adopted ; but Malgaigne says he has seen one instance in which the 
twelfth dorsal spine being broken and displaced laterally, resumed 
its place spontaneously after a few days. Aurran mentions a similar 
example. 2 

Treatment. — If in any case it should be found possible to act upon 
the fragment, an attempt might be made to press it into place, and to 
retain it there by means of a compress and bandage ; but even this 
would not be admissible so long as any doubt remained whether it 
was not a fracture of the vertebral arch, since if it were, any attempt 
to restore the bone to place by pressure would be likely to drive it 
more deeply upon the spinal marrow. Yet what need is there of 
surgical interference of any kind ? If the apophysis remains displaced 
it cannot result in any serious, perhaps we may say in any appreciable 
deformity. The surgeon has therefore only to lay the patient quietly 
in bed and in such a position as he finds most comfortable, enjoining 
upon him perfect rest, and employing such other means as may be 
proper to combat inflammation. 



§ 2. Fractures of the Transverse Process. 

A fracture of a transverse process can scarcely occur except as a 
consequence of a gunshot wound. Dupuytren relates a case of this 
kind in which the ball had penetrated the transverse process of the 
second cervical vertebra. The man bled very little at the time, and 
his symptoms progressed favorably for ten days ; after which second- 
ary hemorrhage occurred, of which he ultimately died. The autopsy 
showed that the vertebral artery had been injured, and that the inflam- 
mation of its coats being followed by a slough, caused his death. 3 

I have also elsewhere reported the case of Charles Harkner, of Buffalo, 
N. Y., who was shot with a pistol on the 21st of Jan. 1851. I did not 
see him until the following day. The ball had entered the chin, a little 
to the left side and below the inferior maxilla, but its place of lodgment 
could not be discovered. He lay with his face constantly turned to 
the right. The left side of his neck was swollen and crepitant ; the left 
arm and leg were paralyzed ; he slept most of the time, but could be 
easily aroused, and when aroused he seemed to be conscious, but was 
unable to speak. By signs he indicated to us that he was suffering 

1 A. Cooper, op. cit., p. 459. 2 Malgaigne, op. oit., p. 412. 

3 Dupuytren, Diseases, &c, of Bones, Syd. ed., p. 360. 



146 . FEACTUEES OF THE VEETEBRJ1. 

no pain. He gradually sank, without hemorrhage, and died in thirty- 
six hours from the time of the receipt of the injury. 

The autopsy, made four hours after death, enabled us to trace the 
wound from the chin, through the left ala of the thyroid cartilage, and 
also through the roots of the transverse process of the fourth cervical 
vertebra ; immediately behind which, lying imbedded in the muscles, 
was the bullet. . The cavity of the tunica arachnoides contained con- 
siderable serous effusion. 

The emphysema in the neck was occasioned, no doubt, by the 
wound of the larynx, the ball having opened freely into its cavity. 
This circumstance also explained the aphonia ; but the immediate 
cause of his death seems to have been arachnoid effusion as a result 
of meningeal inflammation. 

The symptoms arising from this accident can only refer to the com- 
plications, since a mere fracture of the process is not likely to present 
any peculiar signs which could be recognized. Concussion or bloody 
effusion may take place so as to occasion more or less paralysis, or, 
at a later period, inflammation and its consequent effusions may give 
rise to the same phenomenon. 

In itself considered, and independent of these complications, it is 
sufficiently trivial, but inasmuch as it has not been known to occur 
except from gunshot wounds, nor is it likely to occur except from 
penetrating wounds of some kind, the accident must always be re- 
garded as exceedingly grave, if not actually fatal. 

As to the treatment, nothing but strict rest and antiphlogistic 
remedies can prove of any service. 



§ 3. Fractures of the Vertebral Arches. 

The vertebral arches, upon which both the spinous and transverse 
processes have their principal support, may be broken at any point of 

their circumference, by a blow received 
Fig. 33. upon the spinous process; but generally 

it is the lamellar portion, or the " ver- 
tebral plate," which gives way rather 
than the neck or pedicle of the arch; 
and in all of the cases recorded the 
plates have been broken upon both 
sides. 

On the first of May, 1851, during a 
violent storm of wind and rain, a balus- 
trade fell from the top of a high build- 
ing, striking a man named John Larkin, 
who was about forty years of age, upon 
the back of his head and neck. He fell 
to the ground instantly, and did not 
Fracture of the vertebral arch. again move his feet or legs, although 

he never lost his consciousness until he 
died. I found the bladder paralyzed also ; and his left arm, but his 




FEACTUEES OF THE VEETEBEAL AECHES. 147 

right arm he could move pretty well. He conversed freely up to the 
last moment, and said that he was suffering a good deal of pain, which 
was always greatly aggravated by moving. His death took place 
thirty-six hours after the receipt of the injury. 

Dr. Hugh B. Yandeventer, who was the attending surgeon, made a 
dissection on the following day in my presence, which disclosed the 
fact that the plates of the sixth cervical vertebra were broken upon 
each side, and that the spinous process with a small portion of the arch 
attached was forced in upon the spinal marrow. There was no blood 
effused, or serum at this point, but about one ounce of serum was found 
in the cavity of the tunica arachnoides at the base of the brain. The 
bodies of the vertebras were not broken. It was our opinion, there- 
fore, that the immediate cause of his death was the direct pressure of 
the spinous process. 

In the case related by Prout, of Alabama, the man having died 
within forty-eight hours after the receipt of the injury, the arch of the 
fifth cervical vertebra was found to be broken in three places, and the 
spinous process was driven in upon the spinal marrow. There was 
a slight effusion of blood between the sheath of the spinal marrow and 
the bone, and a considerable effusion between the sheath and the cord. 
There was no material lesion of the cord or of its membranes, and the 
body of the bone was neither broken nor dislocated. 1 

It is probable, also, that in the following example the arcli was 
broken, but that the force of the blow having been somewhat oblique, 
the process was but little if at all thrown in upon the spinal marrow. 

E. L., of Erie County, N". Y., aged about forty years, was thrown 
from a loaded wagon in February of 1851, striking, as he thinks, upon 
the back of his neck. He was stunned by the injury, and remained 
insensible several hours ; on the return of consciousness, he found that 
his lower extremities and bladder were paralyzed. During four weeks 
bis bladder had to be emptied by a catheter. Nine months after the 
injury was received he consulted me, and I found the spinous process 
of the last cervical vertebra pushed over to the left side. His head 
was strongly bent forwards, and he was unable to straighten it. He 
could walk a few steps, but not without great fatigue ; and he suffered 
almost constant pain in his lower extremities, accompanied with 
excessive restlessness and watchfulness, for which he was obliged to 
take morphine in large quantities. 

In the case related by Alban Gr. Smith, of Kentucky, to which I 
shall refer again presently, the deviation was lateral, and so also in 
Ollivier's case, mentioned by Malgaigne. 

Symptoms. — We can imagine a case of fracture of the vertebral arch, 
with a lateral displacement only, in which the symptoms might not 
differ essentially from a simple fracture of the spinous process ; and 
it is quite possible that some of the cases which have been supposed 
to be examples of this latter accident, and in which a speedy recovery 
has taken place, were really examples of fracture of the arches ; yet it 

1 Prout, Amer. Journ. Med. Sci., Nov. 1837, vol. xxi. p. 276, from Western Journ. 
of Med. and Phys. Sci. 



148 FRACTURES OF THE VERTEBRA. 

must be admitted that such a fortunate result is only possible, since 
the arches can hardly be broken without communicating a severe 
concussion to the marrow, nor without lacerations, inflammation, and 
effusions, which will be most certain to produce compression and 
paralysis, and probably death. 

If, however, it is possible for us to confound a fracture of the process 
with a fracture of the arches, it is still more possible for us to confound 
a fracture of the arches with a fracture of the bodies of the vertebras. 
If, as is usually the fact, the process, in case of a fracture of the arch, 
is less prominent than natural, and that portion of the body receiving 
its nervous supply from below this point is paralyzed, we may have 
reasons to believe that the arch is broken and the process driven in 
upon the spine ; but dissections have shown that in many of these 
cases, or in most of them, indeed, the bodies of more or less of the 
vertebras are broken also, and in still other cases the bodies were 
alone broken. 

If, as in the case mentioned by Ollivier, we can feel the plates move 
separately, the diagnosis might be made out, so far at least as to deter- 
mine that the plates were broken ; but we should be still unable to 
say that the bodies of the vertebras were not broken also. 

Something perhaps may be inferred from the direction and manner 
of the blow which has produced the fracture. Thus, a fall upon the 
top of the head would most often produce a comminution of the bodies 
by crushing them together, while a blow upon the back could scarcely 
break one of the vertebrae without breaking the corresponding arch 
also. We might thus be led to infer, in the first instance, that the 
arches were not broken ; and, in the second instance, if we could con- 
vince ourselves that the arches were not broken, we might rest pretty 
well assured that the bodies were not. 

In the case related by Prout, there was no external mark of injury 
over the point of fracture, but a distinct crepitus was perceptible on 
pressure. 

Treatment. — If the fragments are not displaced, nothing but rest and 
a cooling regimen are indicated ; but if they are forced in upon the 
marrow, an important question is presented, and which has received 
from different surgeons different solutions. Shall an effort be made 
to reduce the fragments ? and if so, by what means shall the indica- 
tion be attempted ? 

It will be remembered that in nearly all of these cases we must 
remain in doubt, even after the most careful examination, as to the 
actual condition of the fracture. It may be that what we suppose to 
be a fracture of the arch is only a fracture of the apophysis, or that on 
the other hand it is a fracture of the body of the bone itself, and if we 
are expert enough to make out clearly a fracture of the arch, it is not 
possible for us to say that the body is not broken also, indeed it is 
quite probable that it is broken. With a diagnosis so uncertain, can 
we ever find a justification for surgical interference ? Mr. Cline and 
Mr. Cooper thought that we might. According to them, the case pre- 
sents in no other direction a point of hope or encouragement. Death 
is inevitable, sooner or later, if the fragment is not lifted, and we can 



FEACTUEES OF THE VERTEBRAL ARCHES. 149 

scarcely make the matter any worse by interference. If it proves to 
be a fracture of the apophysis, as happened to be the case in a patient 
upon whom Sir Astley operated, 1 our interference was unnecessary, 
but it has done no harm. If the body of the bone is broken, the ope- 
ration affords no resource, but the patient is probably beyond suffering 
damage at our hands. If the diagnosis is correctly made out and the 
arch only is broken, and if, as was the fact in the case of Larkin already 
mentioned, there is no bloody effusion, or laceration of the membranes 
or of the marrow, and if the concussion was not sufficient to deter- 
mine much inflammation of the cord, then it would seem possible that 
an operation might save the patient. 

Paulus iEgineta first suggested that the compressing fragments 
ought to be removed by excision ; and in 1762 Louis removed from 
a man who had received a gunshot wound in his back, after the lapse 
of five days, several loose pieces of bone belonging to the arch of the 
vertebra, and the patient recovered, but not without a partial para- 
lysis of his lower extremities. Of course nothing could be more ra- 
tional or simple than this procedure, adopted by Louis, in any case of 
an open wound, where the fragments could be easily reached ; but the 
younger Cline was the first, in the year 1814, to put into practice the 
more ancient suggestion of Paulus ^Egineta, namely, to attempt the 
removal of the fragments in a case of simple fracture. He made an 
incision upon the depressed bones as the patient was lying upon his 
face, raised the muscles covering the spinal arch, removing by means 
of a circular saw, chisel, mallet, and trephine, &c. the spinous processes 
of the eleventh and twelfth dorsal vertebras, and the arch of one of the 
vertebras. The patient was in no manner relieved, and died on the 
4th day after the receipt of the injury and the 3d after the opera- 
tion. 2 Mr. Oldknow repeated this operation in 1819 in a case of 
fracture of the arch of the seventh vertebra. The patient died on the 
6th day. 3 In 1822, Mr. Tyrrell operated at St. Thomas's Hospital on a 
man who had been injured four days previously, removing the spinous 
processes of the twelth dorsal and first lumbar vertebra. The opera- 
tion was accomplished with considerable difficulty, and resulted in 
only a partial return of sensibility. He died on the 13th day after 
the operation. 4 In 1827, Tyrrell operated a second time, and death 
resulted on the eighth day. 5 On the 30th of August, 1824, Dr. J. 
Ehea Barton, of Philadelphia, operated upon a man who had been 
received into the Pennsylvania Hospital twelve days before, with a 
fracture of the arch of the seventh dorsal vertebra. On the third day 
he was attacked with a violent chill, and death took place twelve hours 
after. The dissection showed about half a gallon of blood in the 
posterior mediastinum, and bloody effusion existed along the whole 
length of the spinal canal. 6 The patient whom Laugier trephined at 

1 Chelius's Surgery, Amer. ed., note by South, vol. i. p. 592. 

2 Cline, Chelius's Surgery, Amer. ed., vol. i. p. 590. 

3 Sir A. Cooper, on Disloc. and.Frac., Amer. ed., 1851, p. 479. 

4 Sir A. Cooper's Loc, by Tyrrell, 3d Amer. ed., 1831, vol. ii. p. 17. 

5 Med.-Chir. Rev., vol. x. p. 601. 

6 Barton, Godman's ed. of Sir A. Cooper on Disloc, &c, p. 421. 



150 FRACTURES OF THE VERTEBRJ3. 

the base of the spinous process of the ninth dorsal vertebra, died on 
the fourth day. 1 The operation has been repeated unsuccessfully by 
Wickham, Attenburrow, Holscher, Heine, and Eoux. 2 

February 5th, 1834, Dr. David L. Kogers, of New York, operated 
upon a man who had fallen two days before, breaking the arch of the 
first lumbar vertebra, and forcing the spinous process upon the cord. 
This man died on the eighth day. 3 

In 1854, Dr. Blackman, of Cincinnati, operated, his patient dying 
on the fourth day. During the same year also, Dr. B. removed a por- 
tion of the sacrum for an injury of four years' standing, with no 
benefit. 4 In 1858, Dr. Stephen Smith, of Bellevue, removed the arch of 
the tenth dorsal vertebra, death occurring soon after. 5 December 29th, 
1857, ten days after the receipt of the injury, Dr. J. C. Hutchinson, 
of Brooklyn, operated upon a man at the City Hospital, Brooklyn, 
removing the spinous processes of the eighth, ninth, and tenth dorsal 
vertebrae, with the posterior arch of the latter. This patient survived 
the operation ten days. 6 Ballingall says, a Dr. Blair has operated 
successfully, but no particulars are given. 

Dr. H. A. Potter, of Geneva, N. Y., informs us that he has operated 
three times. In the first case he states that he removed the posterior 
portion of the three lower cervical vertebrae. The patient died on the 
fourth day. In the second case the doctor removed the spinous pro- 
cesses of the fifth and sixth cervical vertebras, and the entire posterior 
arch of the fifth. The sheath was not broken, " but the cord was much 
injured." There was almost complete paralysis of the extremities, 
and this condition was not remedied by the operation. Three years 
later, the patient being still alive, but only a very slight improvement 
having taken place, Dr. Potter " removed the fourth, sixth, and seventh 
cervical vertebrae." (We presume he intends to say the " posterior 
arches.") At the time of the report, Jan. 1863, there was no further 
improvement. Finally, the doctor reports a completely successful 
case. The injury was of "five months' standing." 7 Packard says, in 
a note to his translation of Malgaigne, that Dr. Potter operated on a 
case of three months' standing, and the patient died on the eighteenth 
day. I suppose this to be the same case. 

These are all of the cases of which we have any information in 
which this operation has been made, and they have all, excepting the 
two cases reported by Potter and the one by Blair, terminated fatally 
in a very few days. The case reported by Alban Gr. Smith, of 
Kentucky, is not related in such a manner as to enable us to make 
use of it safely, nor is it stated how long the patient survived the 
operation ; Gibson says it gave no permanent relief. The example 

1 Malgaigne, Amer. ed., p. 341. 

2 Chelius's Surgery, Amer. ed., vol. i. p. 590. Also, Velpeau's Op. Surgery, 1st 
Amer. ed., vol. ii. p. 737. 

3 Rogers, Amer. Joum. Med. Sci., May, 1835. 

4 Velpeau's Surgery, Blackmail's ed., vol. ii. p. 392; also, Dr. Hutchinson's Paper, 
Trans. N. Y. St. Med. Soc, 1861. 

5 New York Joum. Med., 1859, p. 87. 

6 Hutchinson, Trans. N. Y. Med. Soc , 1861, p. 93. 

7 Amer. Med. Times, Jan. 10, 1863. 



FEACTUEES OF THE VEETEBEAL AECHES. 151 

mentioned by an English writer is equally unreliable, inasmuch as it 
is given only upon rumor, and but a "few months" had elapsed since 
the operation was performed. It was said to have been made in the 
year 1838, by a surgeon of the name of Edwards, in South Wales ; 
and it was affirmed that the compression was relieved and that the 
patient "did well." 1 So unique a case would certainly have found 
before this an ample confirmation. Indeed we must say that none of 
the cases reported as successful give any evidence of authenticity. 

Experience, then, seems to have shown that we have little or nothing 
to expect from this surgical expedient; and noth withstanding the 
strong hope expressed by Sir Astley, that Mr. Cline's operation might 
hereafter prove a valuable resource, and contrary to the conclusions 
which we in common with many other surgeons had drawn from the 
anatomical relations of these parts, we are compelled reluctantly to 
declare that the expedient is scarcely worthy of a trial. To the same 
conclusion also many of the most distinguished surgeons have arrived ; 
among whom we may mention, as especially entitled to confidence, 
Brodie, Liston, Alexander Shaw, Malgaigne, and Gibson. 

What more can be said of the attempt to raise the depressed bone 
by seizing the spinous process with the fingers, or with a pair of strong- 
hooked forceps passed through the skin, or finally, if this cannot be 
done, by laying bare both sides of the process and seizing upon it 
with a pair of firm tenacula ? This is the alternative presented to 
Malgaigne, and which he ventures to recommend as deserving a trial. 
In the absence, however, of any testimony in its favor, beyond the 
mere rational argument adduced by this distinguished writer, we must 
waive any farther consideration of the subject ; only expressing our 
conviction that it will be found, after a fair trial, as useless and as 
inexpedient as the more severe operation of Cline. 

Jeffries Wyman, of Boston, in a private communication, informs me 
that he has met with six examples of fractures of the vertebral arch 
occurring in the fifth lumbar vertebra, between the lower articulating 
and the transverse processes, all of them old, ununited fractures. 
He has also met with the same fracture once in the third lumbar ver- 
tebra. The frequency of this peculiar form of fracture in this region 
Dr. Wyman ascribes to the fact that the upper and lower articulating 
processes are widely separated from each other, and connected only by 
a narrow neck, in which respect they contrast very strongly with the 
dorsal vertebras. The observation is interesting, and, I think, has not 
before been made. 

As to the therapeutical treatment of the various symptoms belong- 
ing to these accidents, and in relation to the prognosis, the remarks 
which we shall make will be found equally applicable to fractures of 
the bodies of the vertebras, and we shall reserve the consideration of 
these topics for the following section. 

1 Edwards, British and Foreign Med. Rev., 1838, p. 162. 



152 FEACTUEES OF THE VEETEBE.E. 

§ 4. Fractures of the Bodies of the Vertebra. 

The same causes which produce fractures of the arches produce also 
fractures of the bodies of the vertebrae, that is, blows received directly 
upon the extremities of the spinous processes ; but in these cases the 
arches are generally broken at the same time. 

In other cases the bodies of the vertebras are broken by falls upon 
the top of the head, by which the vertebrae are not only driven forci- 
bly together, but often doubled forwards upon each other; or the 
patient may have alighted upon his feet or upon his sacrum. 

Keveillon has reported a case of fracture of the fifth cervical verte- 
bra from muscular action, which occurred in diving. The man was 
taken out of the water unconscious, and died in a few hours, having 
declared before death that his head did not strike the bottom, although 
he had jumped from a height of seven or eight feet, and the water 
was only three feet deep. 1 The statement of the sufferer under such 
circumstances could not really possess much value, and we think we 
see good reasons to suppose that he was mistaken. South also relates 
a case of fracture of the fourth and fifth cervical vertebrae occasioned 
by diving, in which it was supposed that the fracture was caused by 
the concussion of the head upon the water. 2 

Malgaigne says the spine bends at three principal points ; comprised, 
the first between the third and seventh cervical vertebrae, the second 
between the eleventh dorsal and second lumbar, the third between the 
fourth lumbar and the sacrum; and that a majority of the fractures of 
the vertebrae occur at these points of flexion. He makes an argument 
from this also that these fractures " are generally the result of counter- 
strokes as the effect of forcible flexion of the column either forwards 
or backwards." Malgaigne observes moreover that dislocations follow 
the same rule. 

The direction of the line of fracture varies greatly in the different 
examples which we have seen ; some are crushed, and more or less 
comminuted. In some cases a narrow piece is chipped from the mar- 
gin, others are broken transversely, and others obliquely. In oblique 
fractures the line of the fracture is generally from behind forwards 
and from above downwards. Malgaigne thinks that a crushing or 
comminution can only occur from a forcible flexion forwards ; but I 
have seen at least one example in which this was not the fact ; the 
patient having fallen so as to strike with the back of his neck upon 
an iron bar. This was the case of the sailor, to which I shall again 
refer more particularly. 

The upper fragment is almost always that which suffers displace- 
ment ; sometimes being simply driven downwards, and thus made to 
penetrate more or less the lower fragment ; at other times, as in cer- 
tain transverse fractures, it is only displaced forwards, and in still 
other examples, where the fracture is oblique, the upper fragment is 
displaced both downwards and forwards. 

1 Reveillon, Chelius's Surg., note by South, vol. i. p. 584. 

2 South, ibid., p. 583. 



FRACTURES OF THE BODIES OF THE VERTEBRJE. 153 



Fig. 34. 




Oblique fracture of the body 
of a vertebra. 



In the first and last of these examples the spine becomes bent for- 
wards at the point of fracture, producing an angle of which the 
most salient point posteriorly is represented 
by the extremity of the spinous process be- 
longing to the broken vertebra; in the second 
example the spinous process of the broken 
vertebra is depressed, and the process of the 
vertebra next below is relatively prominent. 

In a pretty large proportion of cases also 
the fracture of the body of the vertebra is 
complicated, as we have already stated, with 
a fracture of the arches, in some instances 
with a fracture of the oblique processes, and 
with a dislocation. 

Symptoms. — Severe pain at the seat of frac- 
ture, felt especially when the part is touched or 
the body is moved, tenderness, swelling, ecchy- 
mosis, occasionally crepitus, a slight angular 
distortion of the spine, or simply a trifling irre- 
gularity in the position of the processes, and 

paralysis of all the parts whose nerves take their origin below the 
fracture, are the usual signs of this accident. 

The paralysis may be due to the mere pressure of the displaced 
fragments, but it is much more often due to a severe and irreparable 
lesion of the cord itself. I have, in one instance, seen the cord almost 
completely separated at the point of fracture, although the displace- 
ment of the fragments was inconsiderable. 

Accompanying the paralysis of the bladder, there has been generally 
observed an alkaline state of the urine, and subacute inflammation of 
the coats of the bladder. Priapism is present in a certain proportion 
of cases. 

Those who die immediately seem to be asphyxiated ; while those 
who die later seem to wear out from general irritation, this condition 
being frequently accompanied with an obstinate diarrhoea and vomit- 
ing. A few become comatose before death. 

It will be seen, moreover, that a certain proportion finally recover; 
but scarcely ever are all the functions of the limbs and of the body 
completely restored. 

We shall render this part of our description of these accidents more 
intelligible if we regard them as they occur in the various portions of 
the spinal column, since the symptoms, prognosis, and treatment have 
reference mainly to the point at which the fracture has occurred. 



§ 1. Fractures of the Bodies of the Lumbar Vertebrae. 

The spinal cord terminates, in the adult, at the lower border of the 
first lumbar vertebra, but in the child at birth it extends as low as 
the third lumbar vertebra. The remainder of the vertebral canal is 
occupied by the leash of terminal nerves, called collectively the 
cauda equina. 
11 



15-1 FRACTURES OF THE VERTEBRJE. 

The nerves which emerge from the intervertebral foramina below 
the fourth and fifth lumbar vertebrae, unite with the sacral nerves to 
form a plexus which supplies the sphincter and levator ani, the peri- 
neal muscles, the detrusor and accelerator urinae, the urethra, the 
glans penis, and a great proportion of the lower extremities. It will 
be apparent, therefore, that a fracture, with displacement, of even the 
last vertebra of the column, involves the possibility of more or less 
paralysis of all those parts supplied by this plexus, and that in pro- 
portion as the fracture is higher in the vertebral column will the pro- 
bability of additional complications be increased. In other words, 
in addition to the more or less complete loss of function in the organs, 
supplied by the ilio-sacral plexus, there will probably be associated 
loss of function in other organs, supplied from sources above this 
point of the vertebral canal. 

A fracture, however, of the bodies of the fourth or fifth lumbar 
vertebra, produced by a direct blow, is exceedingly rare, owing to 
the protection which it receives from the alae of the pelvis. 

Dr. Alexander Shaw has reported four cases of fracture below the 
second lumbar vertebra, which were unaccompanied with any degree 
of paralysis, and which were followed by speedy recovery, 1 a circum- 
stance which he ascribes to the fact that the cauda equina is composed 
of nerves possessing considerable firmness, and suspended loosely 
together ; for this reason they escape pressure by slipping among 
themselves, and suffer less injury from the same amount of compression 
than the medulla spinalis. 

In the two following cases the results were less fortunate, yet reco- 
veries seem to have taken place. 

A boy was admitted into St. George's Hospital, in Sept. 1827, with 
a fracture and considerable displacement of the third and fourth lum- 
bar vertebrae, the displacement being sufficient to cause a manifest 
alteration in the figure of his spine. His lower limbs were paralytic. 
An attempt was made to restore the displaced vertebrae, but it was 
attended with only partial success. At the end of a month he had 
slight involuntary motions of the lower extremities, and at the same 
time he began to recover the power of using them voluntarily. Three 
or four months after the receipt of the injury he left the hospital, and 
the history of his case was interrupted at this date. 2 

Dr. Thompson, of Goshen, N. Y., reports, also, a fracture of either 
the third or fourth lumbar vertebra, followed by recovery. The 
patient fell from the roof of a house, striking first upon his feet and 
then upon his buttocks. This occurred in October, 1853. The usual 
signs of a fracture were present, such as paralysis, &c. A bed-sore 
formed above the top of the sacrum, and a piece of bone exfoliated 
which, seemed to belong to the last lumbar vertebra. He was con- 
fined to his bed seven months. After eighteen months he began to 
use crutches. At the end of about three years all improvement 
ceased ; at which time he could not quite stand alone, yet with the aid 

1 Shaw, London Med. Gaz., vol. xvii. 

2 Brodie. Sir Ast. Cooper on Disloc, op. cit., p. 471. 



FRACTURES OF THE BODIES OF THE VERTEBRAE. 155 



of apparatus he was able to get about the coun- Fig. 35. 

try and vend books, prints, &c. This was also 
his condition one year later. 1 

A patient in Gruy's Hospital, under Mr. Key, 
with a fracture of the first lumbar vertebra, 
lived one year and two days. On examination 
after death it was ascertained that bony union 
had occurred between the fragments, and that 
the spinal marrow was completely separated 
at the point of fracture. 2 

Mr. Harrold relates a case of fracture of the 
first and second lumbar vertebrae, in which the 
patient survived the accident one year lacking 
nine days ; death having resulted finally from 
a sore on the tuberosity of the ischium and 
disease of the bone. After death it was ascer- 
tained that the fracture had united by bone, 
and that the spinal marrow was almost com- 
pletely cut in two, the divided extremities being enlarged and 
rated nearly an inch from each other. 3 




Key's case of fracture of the 
first lumbar vertebra. 



sepa- 



§ 2. Fractures of the Bodies of the Dorsal Vertebras. 

In these examples, the same organs are paralyzed as in the fractures 
lower down, in addition to which there is generally considerable dis- 
turbance of the functions of respiration, irregular action of the heart, 
indigestion accompanied with a tympanitic state of the bowels. 

Dupuytren, who reports several examples of fractures of the dorsal 
vertebrae, has not taken the pains to record the length of time they 
survived the accident except in two instances, both of which were 
fractures of the eleventh vertebra. One died of suffocation on the 
tenth day, and the other on the thirty-second. In Sir Astley Cooper's 
cases, mention is made of a fracture of the twelfth dorsal vertebra, 
which the patient survived fifty-two days, one of the tenth dorsal, 
which terminated fatally in six days, and another of the ninth dorsal, 
which did not result in death until after nine weeks. 

In 1853 Dr. Parkman presented to the Boston Society for Medical 
Improvement a specimen of fracture of the fifth dorsal vertebra, the 
bodies of the third and fourth being also displaced forwards, in which 
position they had become firmly ossified. The spinal cord had been com- 
pletely separated, yet the patient survived the accident two months. 4 
. Dupuytren has related also two examples of fractures, one of the 
tenth and the other of the last dorsal vertebra, from which the patients 
completely recovered after from two to four months' confinement. 5 A 
similar case is related by Lente, of New York. Barney McGruire, 
having fallen a distance of twelve or fifteen feet -upon his back, was 



1 Thompson, Amer. Journ. Med. Sci., Oct. 1857. Lente's paper, 

2 Key, A. Cooper on Disloc, &c, op. cit., p. 467. 

3 Harrold, A. Cooper, op. cit., p. 464. 

* Parkman, New York Journ. Med., March, 1853, p. 2S6. 
6 Dupuytren, op. cit., pp. 356-7. 



156 FKACTURES OF THE VEKTEBRJE. 

found with nearly complete paralysis of his lower extremites, and of 
his bladder. Swelling existed over the lower dorsal vertebrae, and 
this point was very tender. Subsequently, when the swelling subsided, 
the prominence of the spinous processes of the tenth and eleventh 
dorsal vertebrae put the question of a fracture beyond doubt. Gradu- 
ally under the use of cups, strychnia, mineral acids, laxatives, buchu, 
and electricity, his symptoms improved. In six months he was able 
to walk about the streets, and four years after the accident he was 
employed in a foundry under regular wages, being able to stand fif- 
teen or twenty minutes at a time, and to walk half a mile without 
resting. At this time there remained no tenderness in the spine, but 
the projection of the process was the same as at first. 1 

§ 3. Fractures of the Bodies of the five lower Cervical Vertebrae. 

We shall now have added to the symptoms already enumerated, 
paralysis of the upper extremities, greater embarrassment of the res- 
piration, and more complete loss of sensation and volition in the lower 
part of the body. In general also the eyes and face look congested, 
owing to the imperfect arterialization of the blood, and death is more 
speedy and inevitable. 

In ten recorded examples of fractures of the five lower cervical 
vertebrae which I have been able to collect, one died within twenty- 
four hours, four in about forty-eight hours, one in eleven days, one 
lived fifteen weeks and six days, one about four months, one fifteen 
months, and one, reported by Hilton, survived fourteen years. 2 The 
most common period of death seems therefore to be about forty-eight 
hours after the receipt of the injury. • 

The example of the patient who survived the accident fifteen weeks 
and six days, is recorded by Mr. Greenwood, of England. A woman, 
Mary Vincent, set. 47, was injured by a blow on the back of her neck, 
but she was not seen by Mr. Greenwood until after eleven days, at 
which time she was breathing with difficulty, occasioned by paralysis 
of the intercostal muscles, respiration being carried on by the dia- 
phragm and abdominal muscles alone. This was the extent of the- 
paralysis. There seemed to be a depression opposite the fourth and 
fifth cervical vertebrae, and pressure at this point occasioned universal 
paralysis, as did also the action of coughing and sneezing. About 
three weeks after the accident, she attempted tor the first time to move, 
in order to have her clothes changed, when she was immediately seized 
with paralysis in the right arm and hand. After this she lost her appe- 
tite, had frequent attacks of purging, and thus she gradually wore out. 3 

The patient who survived about four months was admitted into 
Hotel Dieu, under the care of Dupuytren, in 1825, on account of a 
fracture of the fourth cervical vertebra, caused by a fall on the back 
of his neck, and suffering under paralysis of the bladder and extremi- 
ties. After two months and a half of entire rest, he was convalescent 
and quitted the hospital, with only slight weakness in his left leg, and 

1 Lente, Araer. Journ. Med. Sci., Oct. 1857, p. 361. 

2 Hilton, Lond. Lancet, Oct. 27, 1S60. 

3 Greenwood, Sir A. Cooper on Disloc, p. 472. 



FRACTURES OF THE BODIES OF THE VERTEBRAE. 157 

with his head a little bowed forwards. In returning from a long walk 
he fell paralyzed, and remained in the open air all night. From this 
time he continued to fail, and died thirty-four days after the second 
fall. On examination after death, the body of the vertebra was 
found to be broken, and also the processes of the fifth, allowing the 
fourth to slip forwards and compress the cord. A true callus existed 
in front of these bones, which looked as if recently broken. The cord 
itself exhibited an annular constriction, which Dupuytren conceived 
to be the seat of the original lesion narrowed by cicatrization. 1 

The following example furnishes a fair illustration of the usual 
phenomena which accompany fractures of the third or fourth cervical 
vertebra. 

On the 25th of July, 1857, a sailor fell backwards from the wharf, 
striking with the nape of his neck upon a bar of iron. I saw him on 
the following day in consultation with his attending physician, Dr. 
Edwards. He was lying upon his back breathing rapidly. His 
lower extremities were completely paralyzed ; legs and feet swollen 
and purple ; right arm completely paralyzed, and his left partially ; 
from a point below the line of the second rib, there was no sensation 
whatever ; his bowels had not moved, although he had already taken 
active cathartics ; the urine had been drawn with a catheter ; the pulse 
was slower than natural, and irregular. He was constantly vomiting. 
In reply to questions, he said that he felt well, articulating distinctly 
and with a good voice. His eyes and face were somewhat congested, 
but with this exception his countenance did not betray the least phy- 
sical disturbance. He lived in this condition about forty hours, only 
breathing shorter and shorter, and his consciousness remaining to the 
last moment. 

In proceeding to examine the spine a few hours after death, and 
before any incision was made, we were unable, upon the most minute 
examination, to detect any irregularity of the processes of the cervical 
vertebrae, or any crepitus, but on dissecting the neck we found that 
the arches of the third and fourth vertebras were broken, and the 
spinous processes slightly depressed upon the cord. The bodies of 
the corresponding vertebras were comminuted, and the vertebras above 
were driven down upon them, carrying the processes in the same 
direction. The theca and the spinal marrow were almost completely 
severed upon a level with the fourth vertebra. 

A man residing in Erie Co., N. Y., was thrown backwards suddenly 
from the back end of a wagon, alighting upon the top of his head. 
Dr. Mixer having requested me to see this patient with him, I found 
the symptoms almost an exact counterpart of those which belonged 
to the case which I have just described, except that a crepitus and a 
mobility of the fragments could be distinctly felt in the upper and 
back part of his neck. His death occurred in very much the same 
manner after about forty-eight hours. No autopsy was allowed. We 
noticed in this case, also, that whenever he was turned over upon his 
face, respiration almost entirely ceased, but it was immediately restored 
by laying him again on his back. 

1 Dupuytren, op. cit., p. 358. 



158 FKACTUKES OF THE VEETEBEJ. 

Dupuytren, Sir Astley Cooper, South, and other surgeons, have 
related cases simulating fracture, but which proved to be strains of 
the ligaments uniting the cervical vertebrae, accompanied with more 
or less injury to the spinal marrow. In one instance, I have met with 
what has seemed to be a strain of the ligaments and muscles of the 
neck, but which presented no symptoms of serious injury to the spinal 
marrow. 

John Neuman, of Canada West, set. 25, fell bead foremost from a 
height of fourteen feet, striking upon the top of his head. He was 
taken up insensible, and remained in this condition six hours. When 
consciousness returned, his head was very much drawn backwards, 
and it was impossible to move it from this position. There was no 
lack of sensibility or of the power of motion in his limbs, and all the 
functions of his body were in their natural state ; but he has suffered 
with occasional severe pains in his arms ever since. The accident 
happened on the twenty-fourth of November, 1857, and he called 
upon me eight months after. His head was then forcibly bent for- 
wards instead of backwards, into which position it had gradually 
changed. In the morning he generally was able to erect his head 
completely, but after a few hours it was constantly drawn forwards, as 
when I saw him. There was no tenderness or irregularity over the 
cervical vertebrae, and he was so well as to be regularly emploj^ed as 
a day laborer. 

Sir Astley Cooper has collected four examples of what he terms 
" concussion of the spinal marrow," all of which recovered after periods 
ranging from a few weeks to many months ; but in only one case is it 
stated that the recovery was complete. 1 Boyer also enumerates three 
cases of concussion which came under his own observation, all of 
which terminated fatally in a short time. In the first example men- 
tioned by Boyer, the autopsy disclosed neither lesion nor effusion of 
any kind ; in the second case, it does not appear that any autopsy was 
made. The third is related as follows : " A builder fell from a height 
of fourteen feet, and remained for some time senseless ; and, on recover- 
ing from that situation, found that he had lost the use of his inferior 
extremities. He had at the same time a retention of urine, an involun- 
tary discharge of the feces, and some disorder in the function of respira- 
tion. Death followed on the twelfth day after the accident. The body 
was opened, and the vertebral canal was found to contain a sanguineous 
serum, the quantity of which was sufficient to fill a little more than 
its lower half." 2 

§ 4. Treatment of Fracture of the Bodies of the Vertebrse, when the frac- 
ture occurs in any 'portion of the column below the Second Cervical. 

In a few instances, I have noticed among the recorded examples of 
fractures of the bodies of the vertebrae, that surgeons have made some 
slight attempt to reduce the fracture, or rather to rectify the spinal 
distortion, generally by the application of moderate extension to the 

1 A. Cooper, op. cit.. p. 454. 

2 Boyer, Lecture on Diseases of the Bones. Amer. ed., 1805, p. 55. 



FRACTURES OF THE BODIES OF THE VERTEBRAE. 159 

limbs, and by laying the patient horizontally npon a hard mattress. 
But I have not been able to discover that in any case the patients have 
derived benefit from the attempt, although it has been said occasionally 
by the gentlemen making the report, that the deformity was slightly 
diminished. Nor am I aware that in any instance the patient has suf- 
fered any damage from the attempt ; at least the reporter has in no 
case thought it necessary to make this observation. I am confident, 
however, that such manipulation can seldom serve any useful purpose ; 
and I very much fear that it has been frequently a source of mischief. 
Although in cases so generally fatal, it might be very difficult to esti- 
mate with much accuracy the amount of injury done. If by any 
possibility the fragments could be replaced, I know of no means by 
which they could be kept in place ; and in truth we are much more 
likely to increase the penetration of the spinal cord and the general 
disturbance, than to diminish it by extension or pressure. Moreover, 
it usually inflicts upon the unfortunate sufferer great pain, and for 
these reasons, it ought generally to be discouraged. I have recently 
seen one case of fracture of one of the lumbar vertebra?, in which 
relief was afforded by extension. When the fracture is below the 
middle of the vertebral column extension, if employed, should be 
made by adhesive straps, weights and a pulley, as will hereafter be 
directed in fractures of the femur ; the counter-extension being made 
by the weight of the body. It will be understood, however, that 
when paralysis exists the ligation of a limb with bandages will expose 
the patient to great danger of ulceration and sloughing at and below the 
points of pressure, and the amount of extension must be very moderate. 

When treating of fractures of the arches of the vertebrae, I took 
occasion to call attention to Mr. Cline's operation, occasionally recom- 
mended and practised in such cases. I was not ignorant, however, 
that Mr. Cline and several other of the advocates of this operation 
had recommended it especially for fractures of the bodies of the 
vertebras when accompanied with displacement. Even Malgaigne 
has preferred to consider the merits of this operation in its relations 
to these latter fractures ; but while I am prepared to admit the pro- 
priety of an argument as to the value of Cline's operation considered 
in reference to fractures of the arches, I cannot admit its propriety in 
reference to fractures of the bodies of the vertebras. The proposition 
appears to me too absurd to be entertained for a moment. 

The treatment, then, ought to be, in a great measure, expectant. 
The patient should be laid in such a position as he finds most com- 
fortable, and as far as possible, the spine should be kept at rest, since 
the most trivial disturbance of the fragments, and even that which 
may cause no pain to the patient, is liable to increase the injury to 
the spine, and prevent the formation of a bony callus. Especially 
ought the surgeon to be careful, while making the examination, not to 
turn the patient upon his face, in which position the spine loses its 
support and a fatal pressure may be produced. The urine should be 
drawn very soon after the accident, and at least twice daily, for the 
next few weeks. Indeed, it is a better rule to draw the urine as often 
as its accumulation becomes a source of inconvenience, or whenever 
the bladder fills, which will in some cases be as often as every four or 



160 FKACTUEES OF THE VEETEBRJ1. 

six hours. It is especially necessary to attend to those urgent demands 
of the patient during the first few weeks, when the paralysis is most 
complete generally, and the mucous surface of the bladder, already irri- 
tated and inflamed by the excessively alkaline urine, suffers additional 
injury from any degree of painful distension of its walls. It is unneces- 
sary to say that the frequent introduction of the catheter may itself 
prove a source of irritation unless it is managed carefully and skilfully. 
This duty ought never to be intrusted to an inexperienced operator. 

I do not see what advantage the surgeon can expect to derive from 
the administration of drastic purgatives, such as full doses of jalap, 
castor oil, or spirits of turpentine, at any period. If in the first 
instance the bowels are so completely paralyzed as that they seem to 
demand such violent measures to arouse them to action, we may be 
quite certain that the spinal cord is suffering from a pressure, or from 
some lesion which these agents have no power to remedy. The 
bowels may possibly be made to act, but it would be difficult to show 
how this is to relieve the suffering cord. So far from affording relief, 
these measures add directly to the nervous irritation and prostration, 
provoke vomiting and general restlessness. It is not desirable, we 
think, to obtain a movement of the bowels during the first few days 
by any means, however gentle. The effort to defecate, and the conse- 
quent motion, will probably do much more harm than the evacuation 
can do good ; and especially for the same reason ought we to avoid 
putting into the stomach anything which will occasion nausea and 
vomiting. 

After the lapse of a few days, if reasonable hopes begin to be enter- 
tained of a recovery, it will become important to establish regular 
evacuations of the bowels, either by a judicious management of the 
diet, by gentle laxatives, or by enemata. At a still- later period, when 
the inflammatory stage is past, and the nerves remain inactive or para- 
lyzed, nothing could be more rational than the employment of strych- 
nia in doses varying from the one-twelfth to the one-eighth of a grain 
three times daily. ISTor do I think that any single remedy has more 
often proved useful in my own practice, or in the practice of other 
surgeons with whom I am acquainted. In order, however, to derive 
benefit from this or from any other remedy, it must be continued for 
a long time ; perhaps for a year or more. Electricity, setons, issues, 
and blisters are no doubt also sometimes useful. Care must be taken 
that setons, &c, do not produce bed-sores. Passive motion and fric- 
tions; good fresh air, and nourishing diet, become at last essential to 
recovery. From an early period, and during the whole course of the 
treatment, great attention should be paid to the prevention of bed- 
sores, by supporting all of those parts of the body upon which the 
pressure is considerable. For this purpose we may employ circular 
cushions, air-cushions and water-cushions or water-beds ; but with the 
utmost diligence they cannot generally be wholly prevented. When 
the sores have formed they should be treated, if sloughing, with yeast 
poultices, or the resin ointment. I find also the resin ointment an 
excellent dressing for the sores after the sloughs have separated. In 
case the surface is only slightly abraded, simple cerate forms the best 
application. 



FRACTURES OF THE AXIS. 161 



5. Fractures of the Axis. 



The phrenic nerve. is derived chiefly from the third and fourth cer- 
vical nerves. If, therefore, the second cervical vertebra is broken 
and considerably depressed upon the spinal cord ; respiration ceases 
immediately, and the patient dies at once, or survives only a few 
minutes. In such examples of fracture of this bone as have not been 
attended with these results, the displacement and consequent compres- 
sion have been inconsiderable, or there has been no displacement at all. 

Mr. Else, of St. Thomas's Hospital, says that a woman in the vene- 
real ward, and who was then under a mercurial course, while sitting in 
bed, eating her dinner, was seen to fall suddenly forwards ; and the 
patients, hastening to her, found that she was dead. Upon examina- 
tion of her body, it was discovered that the processus dentatus of the 
axis was broken oft; and that the head in falling forwards had driven the 
process backwards upon the spinal marrow so as to cause her death. 1 

Sir- Astley also relates the case of a man who was shot by a pistol 
through the neck, breaking and driving in upon the spinal marrow 
both the "lamina and the transverse process" of the axis. He died 
on the fourth day. 2 

Malgaigne has collected three cases of fracture of the odontoid 
apophysis, all of which were accompanied with a displacement of the 
atlas. The first, reported by Eichet, died on the seventeenth day ; 
the second, reported by Palletta, died after one month and six days ; 
and the third, by Costes, lived four months and two weeks. 

Rokitansky says that there is a specimen contained in the Yienna 
Museum taken from a patient who survived the accident some time, 
although the fragments never united. 

In no case upon record has the patient survived this accident so 
long as in the cas'e reported by Bigelow, and published by Parker, of 
New York. Says Dr. Parker: — 

" The patient, Mr. Gr. B. Spencer, was a man forty years of age, a 
milkman by occupation, of medium height, nervo-sanguine tempera- 
ment, of active business habits, and capable of great endurance. His 
life was one of constant excitement, and he was addicted to the free 
use of liquors. He suffered, however, from no other form of disease 
than occasional attacks of rheumatism, for which he was accustomed 
to take remedies of his own prescribing, which were generally mer- 
curials followed by liberal doses of iodide of potassium, ' to work it 
all out of the system.' 

"On the 12th of August, 1852, while driving a 'fast horse' at the 
top of his speed on the plank road near Bushwick, L. I., he was thrown 
violently from his carriage by the wheel striking against the toll-gate. 
He alighted upon his head and face about fifteen feet from the carriage. 
Upon rising to his feet he declared himself uninjured, but soon after 
complained of feeling faint ; after drinking a glass of brandy he felt 
better, got into his carriage with a friend, and drove home to Riving- 
ton Street in this city, a distance of more than two miles. There was 

1 Else, A. Cooper on Disloc, &c, op. cit., p. 462. 

2 A. Cooper on Disloc, etc., op. cit., p. 47b'. 



162 FBACTUBES OF THE YERTEBE.E. 

so little apparent danger in his case that no physician was called that 
night. Early on the morning of the following day.. Dr. B. was called 
to visit him. He found his patient reclining in his chair, in a restless 
state, and learned that he had suffered considerable pain in the back 
part of his head and neck during the night. He was entirely incapaci- 
tated to rotate the head, which led to the suspicion of some injury to 
the articulations of the upper cervical vertebras; but so great a degree 
of swelling existed about the neck as to prevent efficient examina- 
tion. There was no paralysis of any portion of the body, his pulse 
was about 90, and his general system but little disturbed. Warm 
fomentations were applied to the neck, and a mild cathartic adminis- 
tered. On the following day there was no particular change in his 
symptoms, but as there existed considerable nervous irritability, tinct. 
hyoscyami was prescribed as an anodyne, and fomentations of hops 
applied locally. On the third day, leeches were applied to the neck, 
and after this the swelling so much subsided, that on the fifth day an 
irregularity was discovered to exist in the region of the axis and atlas, 
which had many of the features of a partial luxation of these vertebras. 

'•'At this time he began to walk about the room, having previously 
remained quiet on account of the pain he suffered on moving. He 
persisted in helping himself, and almost constantly supported his head 
with one hand applied to the occiput. He often remarked, if he could 
be relieved of the pain in his head and neck he should feel well. He 
began to relish his food, and the swelling nearly disappeared at the 
end of a week, leaving a protuberance just below the base of the 
occiput, to the left of the central line of the spinal column, with a 
corresponding indendation. Notwithstanding strict orders to remain 
quietly at home, on the ninth day after the accident he rode out, and 
in a day or two after returned as actively as ever to his former occu- 
pation of distributing milk throughout the city to his old customers. 
During the following four months no material change took place in 
his symptoms, although he constantly complained of pain in his head. 
For this period he did not omit a single day his round of duties as a 
milkman, which occupied him constantly and actively from five 
o'clock in the morning to nearly noon. On the first of November, 
Prof. Watts examined him, and inclined to the opinion that there was 
a luxation of the upper cervical vertebrae. 

" About the first of January, 1853, the pains, from which he had 
been a constant sufferer, became more severe, and he was heard to 
complain that he could not live in his present condition ; he remarked, 
also, that he had heard a snapping in his neck. After going his daily 
round on the eleventh of January, he complained of feeling cold, and 
afterwards of numbness in his limbs. In the evening he had a chill, 
and complained of a pain in his bowels. He passed a restless night, 
and arose on the following morning about six o'clock ; he was obliged 
to have assistance in dressing himself, and experienced a numbness of 
his left, and afterwards of his right side. He attempted to walk, but 
could not without help, and it was observed that he dragged his feet. 
He sat down in a chair and almost instantly expired, at 8 o'clock 
A. M., on the 12th of January, precisely five months from the receipt 
of the injury. 



FEACTUEES OF THE ATLAS. 



163 



Fig. 36. 



"The autopsy was made thirty hours after death by Dr. C. E. 
Isaacs, in presence of several medical gentlemen. Muscular develop- 
ment uncommonly fine. An unusual prominence discovered in the 
region of the axis and atlas. On making an incision from the occiput 
along the spines of the cervical vertebras, the parts were found to be 
very vascular. These vertebras were removed en masse, and a care- 
ful examination instituted. The transverse, the odontoid (ligamenta 
rnoderatoria), as also all the ligaments of this region, excepting the 
occipito-axoideum, were in a state of perfect integrity; this latter 
was partially destroyed. A considerable amount of coagulated blood 
was found effused between the fractured surfaces, some of it apparently 
recent, but much of it was thought to have oc- 
curred at the time of the accident, and after- 
wards to have prevented the union of the bones. 
The spinal cord exhibited no appearances of any 
lesion. The odontoid process was found in the 
position well represented in the accompanying 
illustration, completely fractured off, and its 
lower extremity inclining backwards towards 
the cord. Death finally took place, doubtless 
from the displacement of the process during 
some unfortunate movement of the head, by 
which pressure was made upon the cord. The 
destruction of the occipito-axoid ligament, 
which would otherwise have protected the 
contents of the spinal cavity, must have fa- 
vored this result." 1 

Dr. Philip Bevan presented to the Surgical 
Society of Ireland, in 1862, a specimen obtain- 
ed from the dead room, and which was sup- 
posed to be an epiphyseal separation of the odontoid process, occur- 
ring in early life. The history of the case is not known, although 
the woman was forty years old when she died. It does not appear 
very clear to us whether this was really an epiphyseal separation, or 
the result of some morbid process. 2 




Fracture of the odontoid pro- 
cess of the axis. Parker's case. 
A. Broken surface. B. Odon- 
toid process. 



§ 6. Fractures of the Atlas. 

I have been able to find only one example of a fracture of the atlas 
alone, and this is the case related by Sir Astley Cooper as having 
come under the observation of Mr. Cline. 

A boy, about three years old, injured his neck in a severe fall; in 
consequence of which he was obliged to walk carefully upright, as 
persons do when carrying a weight on the head ; and when he wished 
to examine any object beneath him, he supported his chin upon his 
hand, and gradually lowered his head, to enable him to direct his 
eyes downwards. In the same manner, also, he supported his head 



1 Bigelow, New York Journ. Med., March, 1853, p. 164. 

2 Bevan, Am. Journ. Med. Sci., April, 1864. From Dublin Med. Press, Feb. IS, 1863. 



164 FRACTURES OF THE VERTEBRAE. 

from behind in looking upwards. Whenever he was suddenly shaken 
or jarred, the shook caused great pain, and he was obliged to support 
his chin with his hands, or to rest his elbows upon a table, and thus 
support his head. The boy lived in this condition about one year, 
and after death Mr. Cline made a dissection, and ascertained that the 
atlas was broken in such a manner that the odontoid process of the 
axis had lost its support; and was constantly liable to fall back upon 
the spinal marrow. 1 

§ 7. Fractures of the First two Cervical Vertebrae (Atlas and 
Axis) at the same time. 

A woman, set. 68, fell down a flight of steps, striking upon her fore- 
head, and died immediately. Upon making a dissection, it was found 
that the atlas was broken upon both sides near the transverse pro- 
cesses, and the odontoid process of the axis was broken at its base. 
These fractures were accompanied with a rupture of the atloido-odon- 
toid ligaments, and a dislocation of the atlas backwards. 2 

South says there is a specimen in the museum of St. Thomas's Hos- 
pital, showing this double fracture. The man had received his injury 
only a few hours before admission to the hospital, and died on the 
fifth day. On examination, the atlas was found to be broken in two 
places, and the odontoid process of the axis at its root. The fifth ver- 
tebra was also broken through its body. With neither fracture was 
there sufficient displacement to produce pressure, but a small quantity 
of extravasated blood lay in the substance of the spinal marrow, and 
its tissue was at one point broken down and disorganized. 3 

Mr. Phillips relates that a man fell from a hay-rick, striking upon 
the occiput; after which, although momentarily stunned, he walked 
half a mile to the parish surgeon, and in two days more he returned 
to his occupation. About four weeks after the accident he was seen 
by Mr. Phillips, who discovered a small tumor over- the second cervi- 
cal vertebra, pressure upon which caused a slight pain. He com- 
plained also that his neck was stiff, and that he was unable to rotate 
it. No other disturbance of the functions of the body could be dis- 
covered. After a time the tonsils became swollen and the patient 
experienced some difficulty in deglutition, and upon examining the 
throat, a slight projection or fulness was discovered at the back of 
the larynx, opposite the second cervical vertebra. Subsequently he 
became affected with general anasarca and pleuritic effusions, of which 
he finally died. Up to the last week of his life he was able to walk 
about his bed-room, and his condition presented no other evidence than 
has been mentioned, that he was suffering from an injury of the spine. 
He died forty-seven weeks after the receipt of the injury. 

The autopsy disclosed a fracture with displacement of the atlas and 
a 'fracture of the odontoid process of the axis. The two vertebras 
were united to each other firmly by complete bony callus. 4 

1 Cline, Sir Astley Cooper, op. cit., p. 459. 

2 Malgaigne, op. cit., torn. ii. p. 333. 

3 Chelius' Surgery, note by South, vol. i. p. 588. 

4 Phillips, Med.-Chir. Trans., vol. xx. 1837, p. 384. 



FRACTURES OF THE STERNUM. 165 



CHAPTEE XVX. 

FRACTURES OF THE STERNUM. 

Fractures of the sternum are of rare occurrence, owing, probably, 
to the elasticity of the ribs and their cartilages, upon which it mainly 
rests, and also, in part, to the softness of its structure. In advanced 
life, the ossification and fusion of all of its several portions becoming 
more complete, and the cartilages of the ribs also becoming more or 
less ossified, its fracture is relatively more frequent. 

Causes. — They are generally the result of direct blows inflicted upon 
the part, such as the passage of a loaded vehicle across the chest, the 
fall of a tree or of some heavy timber upon the body; the fracture 
implying always that great force has been applied. 

Indirect blows, and voluntary muscular action alone have been 
known also occasionally to produce this fracture. 

David, in his Memoire sur les Contrecoups, published as a prize 
essay by the Academy of Medicine, mentions the case of a mason, who, 
in falling from a great height, struck upon his back against a cross- 
bar which intercepted his fall, in consequence of which the abdominal 
and sterno-cleido-mastoidean muscles were so stretched that the ster- 
num broke asunder between its upper and middle portions. 1 Sabatier 
reports another case of fracture at the same point, produced in a simi- 
lar manner ; 2 and Roland has described a third example in a woman 
sixty-three years old, who, falling from a height backwards and strik- 
ing upon her back, broke the sternum near its centre. 3 

Cruveilhier saw a man who, having fallen from a height of twenty 
feet upon his nates, was found to have a fracture of the sternum. 4 
Cussan saw the same result in a person who fell from a third story, 
striking first upon his feet and then pitching over upon his back. 5 
Maunoury and Thore have reported an analogous case, where a man 
fell from a height of twelve or fifteen metres, first striking upon his 
feet and then falling over upon his back and head. 6 Mr. Johnson, 
late editor of the London Med.-Chir. Rev., reports a case of this kind, 
also, as having been received into St. George's Hospital, in London; 
the man, a healthy laborer, from the country, had fallen from the top 
of a hay cart, striking only upon his head. He walked with his head 
much bent forwards, and was incapable of either flexing, extending, 
or rotating it any further. The fracture was transverse, and about 
three inches below the top of the sternum, opposite the centre of the 

1 Boyer on Bones, p. 57. 

2 Malgaigne, from Sabatier, Mem. sur la Fract. du Sternum. 

3 Ibid., from Bull, de Therap., torn. vi. p. 288. 

4 Ibid., from Bull de la Soc. Anat., Juin, 1826. 

5 Ibid., from Arcbiv. de Med., Jan v. 1827. 
1842, p. 361. 



166 



FRACTUEE3 OF THE STERXUM 



ra/rsli/ unite , 
except in old age 



third rib, the lower fragment projecting in front of the upper. The 
fragments were easily replaced by simply throwing the head back, 
and fell into place with an audible snap, but immediately resumed 
their unnatural position when the head was flexed. They finally 
united, but with a slight projection and overlapping. 1 Gross has 
reported one more example. 2 

Malgaigne expresses a doubt whether all these can be considered 
as the results of muscular action, since in a certain number of the 
examples cited, the head seems to have been thrown forwards by the 
concussion, and in others, also, there is no evidence that the muscles 
attached to the sternum were put upon the stretch. The only remain- 
ing explanation is that in such cases the sternum has been broken by 
the violent shock, or contrecoup. 

Seat and Direction of Fracture. — The sternum is separated most fre- 
quently either in the long cen- 
Fi g- 37. tral portion, or at the junction 

of this with the upper portion, 
where the bone is weakest. In 
fact a separation at this latter 
point may be regarded fre- 
quently as a diastasis or dislo- 
cation rather than as a fracture, 
since the two portions do not 
become firmly united by bone 
until late in life. The very late 
ossification and fusion of the 
xiphoid cartilage with the cen- 
tral piece, also, will explain the 
infrequency of its fracture. 

Boyer believed that the xi- 
phoid cartilage was not suscepti- 
ble of being permanently dis- 
placed backwards, except in 
aged persons after it had become ossified, "for," he says, "though 
violently struck and driven backwards by a blow on what is vulgarly 
termed the pit of the stomach, vet it restores itself by its own elas- 
ticity." 3 

The following; case, however, which has come under mv own ob- 
servation, is conclusive as to the possibility of this accident: — 

A man, twenty-eight years old, fell forwards, striking the lower end 
of his sternum upon the top of a candlestick, breaking in the xiphoid 
cartilage. During two years following the accident he had frequent 
attacks of vomiting, which were excessively violent and distressing; 
the paroxysms occurring every five or six days. Both Dr. Green, 
of Albany, and Dr. "White, of Cherry "Valley, upon whom he called 
for relief, recommended excision of the cartilage, but the patient would 
not submit to the operation. Twelve years after the accident, in the 




35- 40, 



20-25.rt 



l' c 



after pu be rti/ 



artlu cart/iaq incus in 
adva2wed life 



Sternum, showing the periods at which its several 
parts unite by bone. (From Gray.) 



1 London Med.-Chir. Rev., vol. xvii., new series, p. 536. 1S32. 

2 Gross. System of Surg., vol. ii. p. 167. 

3 Boyer on Iiseas.es of Bones, p. 59. 



FRACTURES OF THE STERXUM. 167 

year 1848, while lie was an inmate of the Buffalo Hospital of the 
Sisters of Charity, I examined his chest and found the xiphoid carti- 
lage bent at right angles with the sternum, pointing directly towards 
the spine. He now suffered no inconvenience from it, except that it 
hurt him occasionally when he coughed. 1 

The upper portion of the sternum is rarely broken, unless at the 
same time the central portion is broken also. 

The direction of these fractures is generally transverse, or nearly 
so ; occasionally a slight obliquity is found in the direction of the 
thickness of the bone. In three or four examples upon record, the 
direction of the fracture was longitudinal. It is not so unfrequent, 
however, to find the bone comminuted. Compound fractures are 
exceedingly rare. 

When the fracture is transverse, the lower fragment is almost 
always displaced forwards, and sometimes it slightly overlaps the 
upper fragment. 

In one instance mentioned by Sabatier, where the separation had 
taken place at the point of junction between the first and second 
piece, the lower fragment was displaced backwards, and was also car- 
ried upwards under the upper fragment to the extent of twenty-eight 
'millimetres. 

I have recently seen a remarkable case of separation of the manu- 
brium from the gladiolus, accompanied with a true fracture and other 
complications. 

Louis Wilson, set. 60, was admitted into the Long Island College 
Hospital, April 4, 1866, having just fallen through the hatchway of 
a vessel. He had a compound, comminuted fracture of the right leg ; 
a fracture of the four first ribs on each side at their necks; a dislo- 
cation of the sternum from the cartilages of both second ribs; a 
dislocation of the left third cartilage from its rib ; a dislocation of the 
first from the second bone of the sternum ; and a transverse fracture 
of the sternum three-quarters of an inch below the top of the gladiolus. 
The dislocation of the manubrium was complete, and it was thrust 
behind the upper end of the gladiolus, underlapping it half an inch. 
The transverse fracture three-quarters of an inch lower down was 
also complete, and the fragment thus separated was divided into two, 
namely, an anterior and a posterior fragment, by a transverse splitting; 
the anterior moiety retaining its attachment to the periosteum below, 
and not being displaced, while the posterior moiety retained its 
attachment to the periosteum both above and below, and was pushed 
downwards by the descent of the manubrium. His mind was clear, 
but he had paralysis of the bladder, and was breathing with some 
embarrassment. I had no difficulty in diagnosticating the dislocation 
of the third cartilage, and of the manubrium. There was no swelling 
or discoloration on the front of the chest, but it was quite tender. His 
head was not thrown forward. He complained of some soreness on 
the back of his head. His general condition was such that I did not 
attempt reduction. The following day he expectorated blood, and on 

1 Buffalo Med. Journ., vol. xii. p. 282, Cases of Fractures of the Sternum. 



168 FRACTURES OF THE STERNUM. 

the third day he died. The autopsy revealed some effusions of blood 
underneath the pleura, but no lesions of the heart or lungs. The 
evidence is in this case conclusive that he struck upon his back and 
head, in fact that it was a fracture from counter stroke by which the 
head, neck, and three or four upper vertebrae were bent forward with 
great force, thus doubling forward the top of the sternum. 

Dr. Eobert Watts, Jr., of this city, has reported a very similar case, 
in which death occurred on the same dav. The fragments of the 
sternum were not displaced, but the ribs had suffered similar lesions. 1 

Diagnosis. — In a few cases the patients have felt the bone break at 
the moment of the accident. When displacement exists it may gene- 
rally be easily recognized, and the lower fragment will often be seen 
to move forwards and backwards at each inspiration and expiration. 
Crepitus may also be detected in some of these examples, but it is less 
often present where no displacement exists. To determine the exist- 
ence of crepitus the hand should be placed over the supposed seat of 
fracture, while the patient is directed to make forced inspirations and 
expirations, or the ear may be applied directly to the chest. 

Emphysema has, also, occasionally been noticed, indicating usually 
that the lungs have been penetrated by the broken fragments. 

The frequent occurrence of congenital malformations of the sternum 
should warn us to exercise great care in our examinations, lest we 
mistake these natural irregularities for fractures. Bransby Cooper 
mentions a remarkable instance of malformation of the xiphoid car- 
tilage which he at first suspected to be a fracture. It was so much 
curved backwards that, as Mr. Cooper thinks, its pressure upon the 
stomach produced a constant disposition to vomit whenever he had 
taken a full meal, or had taken a draught of water. 2 

Prognosis. — In simple fracture of this bone, uncomplicated with 
lesions of the subjacent viscera, and especially when the fracture is 
the result of muscular action or of a counter stroke, no serious con- 
sequences are to be apprehended. The bone unites promptly even 
where it is found impossible to bring its broken edges into ap- 
position. Indeed, generally, where the fragments have been once 
completely displaced, although it is not difficult to replace them mo- 
mentarily, a re-displacement soon occurs, and they are found finally to 
have united by overlapping; but no evil consequences usually result 
from this malposition. In nearly all of the cases reported in which 
palpitations, difficult breathing, &c, have been charged to the persist- 
ence of the displacement, the injuries Avere of such a character as to 
furnish for these unfortunate results other and much more adequate 
explanations. In one instance only, already mentioned, serious incon- 
veniences followed from a displacement of the cartilage backwards. 

In other cases, however, where the fracture is the result of a direct 
blow, constituting a large majority of the whole number, the prognosis 
is often very grave : a conclusion to which one would naturally arrive 
from the fact already stated, that the fracture of the sternum thus 
produced, in itself implies the application of great force. 

1 Watts, Am. Med. Times, vol. iii. p. 55. 

2 B. Cooper, Princ. and Pract. of Surg', p. 359. 



FEACTUEES OF THE STEENUM. 169 

An abscess occurring in the anterior mediastinum, and caries or 
necrosis of the bone, are among the most common results of a blow 
delivered directly upon the sternum : complications which generally 
end sooner or later in death. Blood may be also extensively effused 
into the anterior mediastinum. 

A remarkable case of recovery after gunshot injury of the sternum 
is reported by the U. S. Medical Bureau : — 

Private C. Betts, 26th N. J. Vols., set. 22, was struck by a three- 
ounce grape-shot, May 3, 1863, in the charge upon the heights at 
Fredericksburg, Va. The ball comminuted the sternum, opposite the 
third rib on the left side, penetrating the costal pleura. The patient 
removed the ball from the wound himself. On the following day he 
was admitted to the hospital of the second division of the sixth corps. 
Through the wound the arch of the aorta was distinctly visible, and 
its pulsations could be counted. The left lung was collapsed ; when 
sitting up there was but slight dyspnoea. Several fragments of the 
sternum were removed. The wound soon began to heal, and he made 
a complete recovery. 1 

Where emphysema is present we may anticipate inflammation of 
the pleura and of the lungs. 

In several instances, where death has occurred speedily after the 
injury, the heart has been found penetrated and torn by the fragments. 
Sanson and Dupuytren have each reported one example of this kind. 
Duverney has mentioned two, and Samuel Cooper says there is a 
specimen in the museum of the University College, exhibiting a lace- 
ration of the right ventricle of the heart by a portion of fractured 
sternum. Watson mentions a case in which the pericardium was torn, 
but the heart was only contused. 2 

Treatment. — When the fragments are not displaced, the only indi- 
cations of treatment are to immobilize the chest, and to allay the in- 
flammation, pain, &c, consequent upon the injury to the viscera of the 
chest. The first of these indications is accomplished, at least in some 
degree, by inclosing the body, from the armpits down to the margin 
of the floating ribs with a broad cotton or flannel band. A single 
band, neatly and snugly secured, and made fast with pins, is preferable 
to, because it is more easily applied than, the roller which surgeons 
have generally employed ; it is also much less liable to become dis- 
arranged. It should be pinned while the patient is making a full 
expiration. To prevent its sliding down, two strips of bandage should 
be attached to its upper margin, and crossed over the shoulders in the 
form of suspenders. 

Generally the patients prefer the half-sitting posture, with the head 
and shoulders thrown a little backwards ; and this is the position 
which will be most likely to maintain the fragments in place, and also 
to secure immobility to the external thoracic muscles, while it leaves 
the diaphragm and the abdominal muscles free to act. 

The second indication may demand the use of the lancet; but more 

' Circular No. 6, Washington, D. C, Nov. 1, 18S5, p. 23. 
2 New York Journ. Med., vol. iii. p. 351. 

12 



170 FRACTURES OF THE STERNUM. 

often it will be found necessary to allay the pain and disposition to 
cough by the use of opium. 

If, however, the fragments are displaced, it is proper first to attempt 
their reduction; which, as we have already intimated, is generally 
more easy of accomplishment than is the maintenance of them in place 
until a cure is effected. 

The upper fragment may be thrown forwards, and made to resume 
its position sometimes by a single full inspiration; but then it usually 
falls back during expiration; or it may be reduced by straightening 
the spine forcibly and at the same drawing the shoulders back. 

Yerduc and Petit proposed, in those cases in which it was found 
impossible to reduce the fragments by these simple means, to cut 
down and lift the depressed bone. Nelaton suggests the use of a blunt 
crotchet introduced through a narrow incision; and Malgaigne has 
thought of another plan, which is, to penetrate the skin with a punch, 
and directing it to the broken margin, to push the fragment into its 
place, but which he does not himself regard as a suggestion of much 
value, since the bone is too soft to afford the necessary resistance ; and, 
moreover, this, in common with all of the other similar methods, is 
liable, in some degree, to the objection that it may increase the ten- 
dency to caries and suppuration, already imminent. If reduced, the 
fragments will probably immediately again become displaced; and 
more than all, it still remains to be proven conclusively, that the mere 
riding of the fragments is in itself ever a cause of subsequent suffering 
or even of inconvenience. 

When an abscess has formed in the anterior mediastinum, surgeons 
have occasionally recommended the use of the trephine. Gibson has 
twice operated in this manner at the Philadelphia Hospital, but in 
each case the caries continued to extend, and the patient died ; an 
experience which has inclined him latterly to discountenance the 
operation. 1 

There are other considerations mentioned by Lonsdale, which ought 
to decide us never to use the trephine in these cases. "For the symp- 
toms denoting the presence of the abscess, when completely confined 
to the under surface of the bone, will be very uncertain ; and when 
the matter collects in large quantities, it will show itself at the margin 
of the sternum, between the ribs ; when it can be let out by making 
a puncture with the point of a lancet, without the necessity of remov- 
ing a portion of the bone." 2 Ashhurst, referring to the same point, 
remarks: "The fact that the mediastinal space can be cut into without 
injury to the pleura is shown by many cases, among others by one 
which came under my own observation." 3 

We have already said that a separation of the first from the second 
piece of the sternum, occurring before ossific union had taken place, 
might with some propriety be regarded as a diastasis, or as a dis- 
location even. Maisonneuve, Yidal (de Casis), Malgaigne, and other 
French surgeons speak of it as a dislocation, and Yidal has collected 

1 Gibson, Institutes and Practice of Surgery, vol. i. p. 269. 

2 Lonsdale, Practical Treatise on Fractures, London, 1838, p. 242. 

3 Ashhurst, Am. Journ. Med. Sci., Jan. and Oct. 18ti2. 



FEACTUKES OF THE RIBS. 171 

five examples, in all of which the lower bone occupied a position in 
front of the upper. Malgaigne enumerates ten examples. The points 
of difference between the dislocation and the true fracture are too 
small, however, to demand of us especial attention. 



CHAPTEE XVII. 

FRACTURES OF THE RIBS AND THEIR CARTILAGES. 
§ 1. Fractures of the Ribs. 

Fkactukes of the ribs, observed more often than fractures of the 
sternum, are rare as compared with fractures of other long bones. 

In my records, not including fractures from gunshot injuries, only 
twenty-three patients are reported as having had broken ribs ; but as 
in several of the cases two or more ribs were broken at the same time, 
the total number of fractures is about fifty-six. If, however, I had 
always accepted the diagnosis made by other surgeons, the number 
would have been much greater, since I have been repeatedly assured 
that the ribs were broken where, upon the most rigid examination, no 
evidence, beyond the existence of a severe pain and of difficult res- 
piration, has been presented to me. 

Etiology. — The force requisite to break the ribs is scarcely less than 
what is requisite to break the sternum ; and in childhood and infancy 
it is sometimes almost impossible to break them, so that children and 
even adults are often crushed and killed outright, where, although the 
pressure has been directly upon the thorax, the ribs have resumed 
their positions, and have been found not to be broken. I have met 
with several examples of this kind. 

In old age, the cartilages ossify and the ribs themselves suffer a 
gradual atrophy, which renders them much more liable to break. 

The most common causes are direct blows, of very great force, in 
consequence of which sometimes the fragments are not only broken, 
but more or less forced inwards ; occasionally they are the result of 
counter-strokes, and then the fragments, if they deviate at all from 
their natural position, are salient outwards ; a species of fracture which 
I have not met with so often. 

Malgaigne has collected eight examples of fractures of the ribs pro- 
duced by muscular action, by the beating of the heart, &c. ; all of which 
occurred upon the left side. It is believed, however, that in all of 
these cases the ribs had previously become atrophied, and perhaps 
undergone other changes in their structure, rendering them liable to 
fracture from the action of trivial causes. 

Pathology, Seat, &c. — The fourth, fifth, sixth, and seventh ribs are 
most liable to be broken; the upper ribs, and especially the first rib. 



172 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

being so well protected in various ways as to greatly diminish their 
liability, while the loose and floating condition of the last two ribs 
gives them an almost complete exemption. 

In my own cases I have found the first, second, and third ribs each 
broken four times ; the fourth, six times ; the fifth, eleven times ; the 
sixth, twelve times; the seventh, eight times; the eighth, ninth, and 
tenth, twice each. 

Twenty-one were broken through their anterior thirds, generally at 
or near the junction of the cartilages with the ribs ; nine through their 
middle thirds ; and nineteen through their posterior thirds. Mal- 
gaigne has noticed, also, contrary to the general opinion of surgeons, 
that the ribs are most often broken in their anterior thirds, whether 
the cause has been a direct or a counter blow. 

The direction of the fracture is generally tran verse or slightly ob- 
lique ; sometimes it is quite oblique. It is often compound ; and in 
a few instances I have found it comminuted or multiple. Where the 
fracture is compound, it is rendered so generally by the fragments hav- 
ing penetrated the lungs, and not by a tegumentary wound. In only 
eleven of the twenty-three cases seen by me, has the fracture been 
uncomplicated with fractures or dislocations of other bones. 

Displacement cannot occur in the direction of the axis of the bone 
unless several ribs are broken at the same time. The fragments are 
therefore either not at all displaced, or they fall inwards toward the 
cavity of the chest, or outwards, or very slightly downwards, in the 
direction of the intercostal spaces. Sometimes the rib moves a little 
upon its own axis. 

Prognosis. — Death occurs sooner or later in a pretty large propor- 
tion of the cases in which the ribs have been broken; yet not often 
as a direct consequence of the fracture, but only as a result of the 
injury inflicted upon the viscera of the chest, or of other injuries re- 
ceived at the same moment. The violent compression of the heart 
and lungs has frequently produced death, and sometimes, as I have 
more than once seen, almost immediately; or the patients have suc- 
cumbed at a later period to acute pneumonitis. 

Lonsdale saw a case in which the body of a man having been tra- 
versed by the wheel of a wagon, eight ribs were broken, and death 
having followed almost immediately, the autopsy disclosed a rent in 
the left auricle of the heart, produced by one of the broken ribs. 1 — 
South says there is such a specimen in St. Thomas's Hospital. 2 

Dupuytren reports a similar case. The same surgeon has also seen 
several deaths produced by the emphysema, independent of the frac- 
ture, two of which are particularly described in his Clinical Lecture. 3 
Amesbury has seen a case of death from rupture of the intercostal 
artery, where there was no injury of the lungs. 4 

In several instances observed by me, patients have suffered from 
pains in the side, occasionally from cough, &c, after the lapse of two 
or more years, and I suspect it is no uncommon thing for these injuries 

1 Lonsdale on Fractures, p. 258. 2 Chelius's Surgery, by South, vol. i. p. 599. 
3 Dupuytren, op. cit., p. 79. 4 Amesbury on Fractures, vol. ii. G12. 



FRACTURES OF THE RIBS 



173 



to entail some such permanent disability, but which is a consequence 
rather of the injury to the viscera of the chest than of any condition 
of the broken ribs themselves. 

In general, simple fractures of the ribs unite in from twenty-five to 
thirty days. Malgaigne has seen one case of non-union ; Huguier met 
with another upon the cadaver, in which a complete false joint existed, 
furnished with a capsule and lined with synovial membrane ] l Eve, of 
Nashville, Tenn., saw a case of non-union occasioned, probably, by a 
caries or necrosis of the bone, since it was accompanied with a dis- 
charge of matter, and in which a removal of the ends of the fragments 
resulted promptly in a cure of the sinus; 2 and Samuel Cooper says 
there is a specimen in the Museum of the University College, of a 
fracture of six ribs, where the fragments are only connected by a 
fibrous or ligamentous tissue. 3 

The union generally occurs with only a slight degree of displace- 
ment. 

After the union is completed, even where there is no displacement, 
a certain amount of ensheathing callus may generally be felt at the 
point of fracture. Of five cases which I have carefully examined after 
recovery, in only one instance was I unable to detect any irregularity 
at this point. I have in my cabinet nine specimens of fractured ribs. 
in four of which the ensheathing callus is completely formed, but the 
fragments are in perfect apposition : in one, apposition is preserved, but 
there is no ensheathing 

callus ; and the remain- Fig. 38. 

ing four, all occurring 
in the same person, 
are united with displace- 
ment, but without a pro- 
per ensheathing callus. 

In some specimens I 
have observed sharp spi- 
cule, in others broader 
sheets, of bone extend- 
ing along the course of 

o _ o Fractured ribs joined to each other by osseous matter. (From 

the interCOStal mUSCleS Dr. Gross's cabinet.) 

from one rib to the 

other, forming a species of anchylosis between their adjacent margins. 

Symptomatology. — Acute pain, referred especially to the point of 
fracture, sometimes producing great embarrassment in the respiration, 
and crepitus, are the most common indications of a fracture. The pain 
and embarrassed respiration are, however, far from being diagnostic, 
since they are often present in an equal degree when the walls of the 
chest have only been severely contused. 

The crepitus, also, is often difficult to detect, owing to the thickness 
of the muscular coverings, or to the amount of fat upon the body, or 
to the fracture having occurred perhaps directly underneath the mam- 
mas in the female. In three instances, where the presence of emphy- 




1 Malgaigne, op. cit., p. 435. 
S. Cooper's Surg., vol. i\. p. 321. 



2 Eve, N. Y. Journ. Med., vol. xv. p. 13(3. 



174 FKACTUKES OF THE EIBS AND THEIK CAKTILAGES. 

sema rendered the existence of a fracture quite certain, I have been 
unable immediately after the accident to discover crepitus. 

The crepitus may be discovered sometimes by pressing gently upon 
the seat of fracture, or by applying the ear or the stethoscope over 
this point while the patient attempts a full inspiration, or coughs ; or 
we may press upon the front of the chest with one hand, while the 
ringers of the other hand rest upon the fracture. 

Occasionally the patient has felt the bone break, and very often he 
feels or hears the crepitus after it is broken, and will himself indicate 
very clearly the point of fracture. 

At the same time that we detect crepitus we are able also to discover 
motion in the fragments, but I have once or twice discovered preter- 
natural mobility without crepitus. 

Emphysema, which is almost certainly indicative of a fracture, is 
present in a pretty large proportion of cases. It has been observed by 
me in eleven out of twenty-three cases ; generally it did not extend 
over more than two or three square feet of surface ; but in one instance 
it finally extended over nearly the whole body. It is remarkable, 
however, that in only four of these eleven .cases did the patients ex- 
pectorate blood, and then in a very small quantity, and not until the 
second or third day. 

Desault observes that emphysema rarely succeeds to fractures of 
the ribs ; an observation which, as will be seen, my experience does 
not at all confirm. 

Treatment. — In simple fractures, where there is no displacement, or 
where the displacement is only moderate, the chest may be inclosed 
with a broad belt or band, as we have already directed in case of frac- 
ture of the sternum: provided always that it is not found to increase 
instead of diminishing the patient's sufferings. Some patients cannot 
tolerate this confinement at all, while with a majority, although it is 
at first uncomfortable and oppressive, after an hour or two it affords 
great relief from the distressing pain, and they will not consent to 
have it removed even for a moment. In nearly all cases of commi- 
nuted fracture, it is inadmissible, on account of its tendency to force 
the pieces inwards. 

Hannay, of England, has suggested the use of adhesive strips as a 
substitute for the cotton or flannel band ; the several successive pieces 
being imbricated upon each other until the whole chest is covered. 1 
The same objection holds to this mode of dressing as to a similar mode 
of dressing a broken clavicle, which has been recently recommended. 

It will certainly become loosened after a few hours, by the slight 
but uninterrupted play of the ribs. 

The forearm ought also to be brought across the chest at a right 
angle with the arm, and secured in this position with a moderately 
tight bandage or sling, so as to prevent any motion in the pectoral 
muscles. 

As to position, the patient generally prefers to sit up, or he chooses 
a position only partly reclining upon his back ; but there is no positive 

1 American Jouru. Med. Sci., vol. xxxix. p. 19S. From Lond. Med. Gaz., Nov. 1845. 



FEACTUEES OF THE EIBS. 175 

rule to be observed in this matter, except that such a position shall be 
chosen as shall prove most comfortable to the patient. 

If the fragments are salient outwards, the fracture having been pro- 
duced by a counter-stroke, they may be reduced by pressing gently 
upon them from without, If, on the contrary, the fragments are salient 
inwards, they will be found, in a great majority of cases, to have re- 
sumed their positions spontaneously or through the natural actions of 
respiration ; but if they have not, it will be exceedingly difficult to 
restore them. Possibly it may be accomplished by pressing forcibly 
upon the front of the chest, or upon the anterior extremity of the 
broken rib ; yet if the fragments are comminuted, and the ends are 
much driven in, this method will avail little or nothing. In such cases 
several surgeons have recommended that we should cut down to the 
bone and elevate the fragments, but Eossi alone claims to have actu- 
ally put the suggestion into practice. 

No doubt, if the necessity was urgent, this method might be suc- 
cessfully adopted ; or, instead of cutting down to the broken rib, we 
might even seize the fragment with a hook, as suggested by Malgaigne, 
.or, what in some cases might be even more convenient, with a pair of 
forceps constructed with long teeth, obliquely set upon a firm shaft. 
Yet the exigency which will demand a resort to any of these measures 
will be exceedingly rare. In gunshot fractures, which are nearly all 
compound and comminuted, the loosened or detached fragments should 
be at once removed. 

In no case do I attach any value or importance to the advice given 
by Petit, that we shall place a compress upon the front of the chest, 
underneath the bandage, in order to reduce the fragments, or to retain 
them in place after reduction. Lisfranc, who advocated this method, 
claimed that its advantage consisted in the increased length which 
was thus given to the antero-posterior diameter of the chest, and the 
consequent accumulation of pressure from the encircling band, in this 
direction. 1 The mechanical law is no doubt correctly stated, but its 
value in practice is too inconsiderable to deserve consideration. 

The emphysema generally demands no especial attention, since it is 
usually too limited to occasion inconvenience, and when more exten- 
sive it generally disappears spontaneously after a few days, or a few 
weeks at most. The advice given by some surgeons, that we ought 
in these cases to cut down to the pleural cavity so as to allow the air 
to escape freely through the incision, seems thus far to have rested its 
reputation upon a more than doubtful theory rather than upon any 
testimony of experience. Abernethy alone, so far as I know, has 
actually made the experiment, and his patient died. 

Dupuytren, in the two cases already alluded to, bled the patients 
and applied resolvent liquids, with rollers; he also made incisions 
with the lancet at various points of the body, more or less remote from 
the seat of fracture, a practice, however, in which he confesses he has 
no confidence whatever. These patients both died. 

Dr. Stedman, of the Massachusetts General Hospital, has reported the 

1 Ranking's Abstract, vol. ii. p. 204, from Gaz. des Hopitaux, July 8, 1S-15. 



176 FRACTURES OF THE RIBS AXD THEIR CARTILAGES. 

case of a man aged sixty-nine, of intemperate habits, who, in addition to 
a fracture of one of his ribs, had also a dislocation of the outer end of 
the clavicle. The emphysema commenced immediately and reached 
its acme on the twenty-second day. At this time it had extended over 
his whole body; his eyes were closed and he breathed with great 
difficulty; but on the forty-fifth day, the emphysema had entirely 
disappeared, and he was dismissed cured. The treatment consisted 
chiefly in the free internal use of stimulants, and in the application of 
bandages ; but the bandages soon became disarranged, and after a few 
days they were entirely laid aside. 1 

In the case of my own patient, where the emphysema was almost 
equally extensive, the patient recovered after a few weeks, under the 
use of a simple diet, and without any special medication whatever. 



§ 2. Fractures of the Cartilages of the Ribs. 

Boyer was incorrect when he said that the cartilages of the ribs 
could not be broken until they were ossified. They are often broken 
when there is no ossification, at the same time that the ribs themselves 
are broken. Sometimes they are broken alone. Not unfrequently, 
also, the separation takes place at the precise point of junction between 
the two. 

Pyper relates a case in which the sternum was broken in a man 
aged twenty-five years, and also the cartilages of the sixth, seventh, 
and eighth ribs of the right side, as was proven by the autopsy, yet 
the cartilages were not ossified. The vena cava ascendens was also 
raptured by the force of the compression. 2 The reader is referred 
also to my own and Dr. Watts' cases reported in the chapter on Frac- 
tures of the Sternum. 

Etiology. — The causes are the same as those which produce fractures 
of the ribs, yet it is generally understood that it will require greater 
force, and that consequently the injury done to the viscera of the 
thorax will be more complicated and intense. 

In the reports of the Massachusetts General Hospital, an account is 
given of the case of a man aged thirty, who was crushed by the fall 
of a heavy weight upon his body, and who died after about sixty 
hours. An examination after death revealed a fracture of the car- 
tilages of the third and fourth ribs, with a laceration of the intercostal 
muscles to such an extent that a hernia of the lungs had occurred at 
this point. This hernia had been discovered and recognized by Dr. 
"Warren, soon after the accident occurred ; the protrusion being at 
that time as large as the clenched fist and regularly rising and falling 
with each movement of respiration. It was accompanied, also, with a 
moderate emphysema. 

Pathology. — The fracture is clean and vertical, or transverse; never 
irregular or oblique. The direction of the displacement varies as in 

1 Boston Med. and Surg. Journ., vol. lii. p. 316. 

2 Ranking's Abstract, vol. i. p. 147. from the Lancet, Oct. 1844. 



FRACTURES OF THE CLAVICLE. 177 

fractures of the ribs, but the anterior or sternal fragment is generally 
found in front of the posterior or spinal. 

Union takes place in these fractures, not through the medium of 
cartilage, but of bone. Sometimes the new bone being deposited only 
between the ends of the fragments, in the form of a thin plate, and at 
other times it is formed around the fragments as well as between 
them. The latter of these two processes has been most frequently 
observed. The ensheating callus appears to be supplied by the peri- 
chondrium, while the experiments of Dr. Eedfern render it probable 
that the intermediate callus may result from a conversation or trans- 
formation of the adjacent cartilaginous surfaces. Paget remarks, also, 
that the ossification extends to the parts of the cartilage immediately 
adjacent to the fracture. 

I have seen one example, in the person of Hiram Leech, set. 38, 
which, after the expiration of more than one year, had not united. 
The fracture had occurred in the united cartilages of. the tenth and 
eleventh ribs. The posterior fragment overlapped the anterior, and 
they played freely upon each other at each act of inspiration and 
expiration. 

I do not know that any observations have been made upon the 
repair of these cartilages in very early life, and it is possible that the 
process may differ from this which has been described as it has been 
observed in the adult. 

Treatment. — The treatment need not differ from that already recom- 
mended for fractured ribs. 



CHAPTEE XVIII. 

FRACTURES OF THE CLAVICLE. 

For the sake of convenience, I shall divide fractures of the clavicle 
into those occurring through the inner, middle, and outer thirds. By 
the " outer third" is meant all that portion of the clavicle included 
between its scapular extremity and the internal margin of the conoid 
ligament. The remaining portion is intended to be divided equally 
into two separate thirds. The peculiarities of these several portions, 
in respect to anatomical relations, liability to fracture, results, etc., will 
explain the propriety of the divisions. 

Causes. — If we except gunshot fractures, the clavicle is broken, in 
a large majority of cases, by a counter stroke, such as a fall, or a blow 
■upon the extremity of the shoulder. 

Occasionally it is broken by a direct stroke, as when a blow aimed 
at the head is received upon the shoulder ; it is broken sometimes by 
the recoil of an overloaded gun, especially when the person lies upon 
the ground with the butt of the gun resting against the clavicle. 

Gibson has seen a case in which it was broken in a child at birth, 



lib FEACTURES OF THE CLAVICLE. 

by an ignorant midwife pulling at the arm, 1 and Dr. Atkinson has re- 
ported an example of intra-uterine fracture of the clavicle. 2 

I have once seen the clavicle broken by muscular action alone. A 
large, well-built and healthy man, aged thirty-seven, standing upon 
the ground, attempted to secure the braces of his carriage top with his 
right arm, when he felt a sudden snap, as if something about his 
shoulder had given way. He did not, however, suspect the nature of 
the injury, and did not consult any surgeon until eight days after, at 
which time I found the right clavicle broken near its centre, but 
rather nearer the sternal than scapular extremity. The fragments 
were but slightly, if at all displaced, but motion and crepitus at the 
point of fracture were distinct. The usual node-like swelling was 
also present, indicating the existence of a considerable amount of en- 
sheathing callus. He had been unable to raise the arm to a right 
angle with the body since it was broken, but he had suffered no other 
inconvenience from it. 

A similar case is reported in the number for January, 1843, of the 
American Journal of Medical Sciences, copied from the Revista Medica. 
The subject of this case was a colonel of cavalry, about sixty years of 
age. In mounting his horse, he experienced a sensation as if some- 
thing had broken, followed by acute pain in his left shoulder, and, on 
examination, it was found that the clavicle was fractured in the mid- 
dle. The health of this gentleman ' had been impaired, it is further 
stated, by repeated attacks of syphilis. 

Malgaigne has recorded three other examples of fracture of this 
bone from muscular action; and Parker saw a case which was pro- 
duced by striking at a dog with a whip; the bone had been previously 
somewhat diseased, yet it united favorably. 3 

Of these six cases, five occurred on the right side, and always near 
the middle of the bone, if we except one case reported by Malgaigne, 
in which the point of fracture is not mentioned. In neither case did 
the fragments become displaced, only as they were found, in some of 
the examples, inclined slightly forwards. 

Pathology. — It has already been observed, in speaking of partial 
fractures, that this bone suffers an incomplete fracture more often 
than any other, and that in such cases, the lesion occurs generally in 
the middle third, or rather to the sternal side of the centre, and in a 
direction nearly or quite transverse. They are not usually accom- 
panied with much displacement, but if a displacement exists, it is a 
slight forward inclination of the fragments. 

Fractures which are complete occur mostly after the bones have 
become firm and unyielding. They are also generally oblique, seldom 
comminuted, still more rarely compound. The point of the clavicle 
at which a complete fracture usually occurs, is at or near the outer 
end of the middle third, and a little to the sternal side of the coraco- 
clavicular ligaments, near where the trapezius and deltoid cease their 
attachments. It might be more exact to say, that the fracture extends 

1 Gibson, Principles of Sur., sixth el., vol. i. p. 272. 

2 Atkinson. Bost. Med. and Sursj. Journ., July 26, 1830. 

3 Parker, N. Y. Journ, Med., July, 1852. 



FRACTURES OF THE CLAVICLE. 



179 



from this point downwards and inwards, toward the sternum, em- 
bracing one inch or less of its entire length. In some cases the obli- 
quity is greater, and the amount of bone involved is much more 
considerable. 

Why the bone should break more frequently at this point, espe- 
cially in the adult and in the male, it is not difficult to understand. 
It is smaller here than elsewhere, and less supported by muscular and 
ligamentous attachments. At this point, also, the axis of the bone 
begins pretty abruptly to curve forwards, and more .abruptly in the 
adult and male, than in the child and female. When, therefore, the 
clavicle is broken, as it usually is, by a counter-stroke, the force of 
the blow, conveyed from the shoulder through the outer portion of the 
bone, is suddenly arrested, and expends itself upon the point where 
the direction of the axis is changed. 

In a record of one hundred and five fractures, including partial and 
comminuted, and not including gunshot fractures, eighty-eight have oc- 
curred through the middle third; 
and, with the exception of the partial 
fractures, the fracture has in nearly 
all of the cases taken place near the 
outer end of this third. Four have 
occurred through the inner third, 
three of which were within one 
inch of the sternum; and thirteen 
through the outer third. 

A more practical analysis can be 
based, however, upon the point of 
fracture with reference to its cause ; 
and I have never, but once, seen a 
complete fracture of this bone pro- 
duced clearly by a counter-stroke, 
winch was not near the outer end 
of the middle third. 

When the fracture is at this 
point, or in any portion of the mid- 
dle third, the direction of the dis- 
placement is almost uniformly the 
same. The sternal fragment is 
slightly lifted by the action of the 
clavicular portion of the sterno- 
cleido mastoid muscle, notwith- 
standing the resistance of the rhom- 
boid ligament, and the subclavian muscle. On the other hand, the 
acromial fragment is dragged downwards by the weight of the arm, 
aided by the conjoined action of a portion of the pectoralis major and 
the latissimus dorsi, feebly resisted by the trapezius and other mus- 
cles from above; by the action of the same muscles, aided by the 
pectoralis minor, and perhaps by some portion of the subclavius, it is 
drawn toward the body, diminishing thereby the axillary space ; while 
by the preponderating strength of the pectoralis major and minor, the 




Complete oblique fracture of clavicle, near its 
middle. (From Gray.) 



180- FRACTURES OF THE CLAVICLE. 

acromial end of the fragment, with the shoulder, is drawn forwards ; 
the sternal end of the same fragment being rather displaced backwards, 
and at the same time resting at a point somewhat elevated above the 
acromial end. 

Desault has recorded one example of an overlapping by the eleva- 
tion of the acromial fragment over the sternal; 1 and Bichat remarks, 
that Hippocrates speaks of the phenomenon as a thing which was 
familiar to him. Syme has mentioned a case of this kind which he 
had seen. 2 Grueretin, Malgaigne, 3 and Stephen Smith, have each re- 
ported an example. 4 In Stephen Smith's case, the fracture occurred 
in a man thirty-eight years old. The bone was broken through the 
outer third, and transversely. He was treated at the Bellevue Hos- 
pital, but the overlapping, to the extent of one inch, remained after the 
cure was completed. 

In nearly all the cases of oblique fractures occurring through the 
middle third, there follows immediately an overlapping, varying from 
one-quarter of an inch to an inch, and sometimes, though very rarely, 
exceeding this. There is a specimen in the Dupuytren Museum, in 
which the shortening equals one-third of its entire length. 

Transverse fractures, wherever they may occur, are not so constantly 
found displaced, at least in the direction of the axis of the bone, as the 
following examples will illustrate : — 

An old lady, aged eighty years, fell down a flight of stairs, break- 
ing the right clavicle transversely, about one inch from the sternum. 
I saw her, with Dr. Trowbridge, ou the day following the accident. 
Motion and crepitus were distinct, but there was scarcely any dis- 
placement. ISTo dressings were applied, but she was directed to keep 
quiet in bed, and upon her back. In the usual time the fragments 
had united, without deformity. 

A man, about forty years old, fell backwards from a wagon, break- 
ing the collar bone near the middle. The fragments were movable, 
but not displaced. He was treated successfully and without any re- 
sulting deformity, by simple confinement in the recumbent posture 
during a few days, and after this by suspending the arm in a sling, 
while he was permitted to walk about. 

A young man, aged twenty-six, fell while wrestling and broke the 
clavicle at the outer end of the middle third. There was some dis- 
placement at first, but the fragments being reduced, were found to sup- 
port themselves. A cross, secured with straps, was applied to the 
back, and on the twenty-eighth day the union was complete, and with- 
out deformity. 

A child, aged three years, fell about six feet, striking upon his 
shoulder. He was sent to me on the same day, by Dr. Gr. Bur well. 
I found the left clavicle broken off completely, about one inch from its 
scapular end. Crepitus and motion were distinct, but the fragments 
were not displaced. The arm was placed in a sling, and on the seventh 
day both motion and crepitus had ceased. The cure was accomplished 
without any degree of displacement. 

1 Desault on Frac. op. cit.. p. 16. 2 Ampr. Journ. Med. Sei., vol. xvii. p. 251. 
3 Malgaigne. p. 461. 4 N. Y. Journ. of Med., May, 1857. 



FRACTUKES OF THE CLAVICLE. 181 

The example of a fracture from muscular action, already mentioned 
as having been seen by me, was also probably transverse, and union 
has occurred without treatment and without displacement. 

Stephen Smith, of New York, has met with two examples of trans- 
verse fractures without displacement, in a hospital record of eleven 
cases. Bichat says Desault has frequently observed the same, it 
having been seen three times at Hotel Dieu, in the course of the year 
1787. 1 Desault thinks, also, that sometimes the fracture, taking place 
obliquely upwards and inwards, the usual form of displacement is 
prevented, and apposition is preserved. 

If the fracture is near the sternum, and within the fibres of the 
costo-clavicular ligaments, as in the case of the old lady just cited, the 
displacement is inconsiderable. I have seen one other similar case in 
an adult also. Lonsdale mentions a case in a child, three years old, 
which came under his observation in Middlesex Hospital, 2 which he 
regarded as a separation of the epiphysis ; this bone, however, has no 
epiphysis, properly speaking, being formed entire from a single point 
of ossification. Malgaigne mentions two other examples, in one of 
which the fracture was so near the sternum that it was difficult to say 
whether it was not a partial dislocation. The displacement was only 
trivial. 3 But the only two specimens contained in the Dupuytren 
Museum offer a considerable displacement, and in both the external 
fragment is thrown downwards and forwards. 

March 22, 1865, 1 presented to the New York Pathological Society 
a similar case, obtained from a patient in Bellevue Hospital. The 
man from whom this specimen was taken, was forty-five years old, and 
the fracture, occasioned by a fall upon the shoulder, extended from the 
sterno-clavicular articulation upwards and outwards one inch and a half. • 
The fragments were overlapped three-quarters of an inch, and were 
firmly united. The character of the accident was not recognized 
until after death. The specimen is now in the museum of the Bellevue 
Hospital. 

With regard to the amount of displacement usually attendant upon 
fractures near the outer end of the bone, surgical writers have gene- 
rally united in declaring that it was in a majority of cases very incon- 
siderable, while some have even affirmed that there would be found no 
displacement whatever ; neither of which opinions, according to the 
observations of Robert Smith, of Dublin, is strictly correct. He has 
examined eight specimens of fracture of the outer extremity of the 
clavicle, contained in the museum of the Eichmond Hospital School 
of Medicine; three of which were broken between the conoid and 
trapezoid ligaments, and are united with very little displacement, 
while the remaining five, broken beyond the trapezoid ligament pre- 
sent a very marked deformity. 

The following is a summary of the conclusions to which he has 
arrived: — 

"When the clavicle is broken between the two fasciculi of the 

' "Desault on Fractures, op. cit., p. 15. 2 Lonsdale on Fractures, p. 206. 

3 Malgaigne, op. cit., p. 491. 




182 FRACTURES OF THE CLAVICLE. 

coracoclavicular ligament, there is seldom any displacement of either 
fragment, and always much less than in fracture of any other portion 
of the bone. TThen displacement does occur, it is usually limited to 
a slight alteration in the direction of the bone, by which the natural 
convexity of this portion of the clavicle is increased. 

" The explanation of which facts is found in the attachments of the 
ligaments from below to the two fragments ; and, in the action of the 
trapezius from above, by which they are antagonized. 

" But the case is very different when the bone is broken external to 
the trapezoid ligament. Here the coraco-clavicular ligaments can 
have no direct influence upon the outer fragment, which is displaced 
now partly by muscular action, and partly by 
Fi s- 40 - the weight of the arm, the sternal end of the 

outer fragment being drawn upwards by the 
clavicular portion of the trapezius, while, by 
the action of the muscles passing from the chest. 
the entire outer fragment is drawn forwards and 
inwards, so as to bring sometimes its broken sur- 
face into contact with the anterior surface of the 

Fracture outside of trapezoid .. 

ligament. United. inner fragment, and placing it nearly at right 

angles with this fragment, in which position it is 
generally united. The displacement in this direction,rather than any 
degree of overlapping, explains also the shortening which existed in 
all of these, cases, varying in the different specimens from half an inch 
to one inch, and averaging about three-quarters of an inch." 

Such are the views of Mr. Smith, and I see no reason to call in 
question their correctness. In my own experience, a fracture occur- 
ring in a child three years old, within one inch of the acromial end, 
probably between the ligaments, was never displaced at all ; a second 
occurring somewhere in the outer third, presented, after many years, 
no displacement. Two recent cases were displaced each one-quarter 
of an inch, and one old case, half an inch ; these three latter cases 
occurred in adults, and always within an inch of the acromial end of 
the bone. In one of these last examples, the inner fragment was 
rather behind than above the outer fragment. 

But it would be unsafe to draw conclusions from an experience 
which is confined entirely to living examples, and in which no dissec- 
tions have been made, to verify the exact point of fracture, or the 
precise amount and character of the displacement. So far as they go, 
however, they seem to me to confirm the general correctness of the 
observations made by Eobert Smith. 

It has happened to me only six times to meet with a comminuted 
fracture of the clavicle, except in cases of gunshot injuries, all of which 
fractures occurred through some portion of the middle third of the 
bone ; the intercepted fragments being from one inch to one inch and 
a half in length, and lying obliquely, or, as in one case observed by 
me, at nearly a right angle with the main fragments. 

I have never seen a compound fracture of this bone, except as the 
result of a gunshot injury, although, in many cases, the sharp point 
of an oblique fracture has seemed just ready to penetrate the skin. 



FRACTURES OF THE CLAVICLE. 



133 



One case is reported as having been presented at St. Bartholomew's 
Hospital. It occurred in a boy fourteen years old, and was produced 
by his having been drawn into some machinery while it was in motion. 1 
Two similar cases are reported from the New York Hospital, as having 
been observed during the last ten years. The whole number of ex- 
amples of fracture of the clavicle during this period was 19 1. 2 

Lente also mentions a case, seen by himself, occasioned by the fall 
of a derrick upon the shoulder. The patient, twenty-four years old, 
was admitted into the New York Hospital in August, 1848. The left 
clavicle was broken at about its middle, and a large wound in the 
integuments communicated with the fracture. The fragments united 
firmly in about six weeks, after several pieces of bone had been dis- 
charged from the wound. 3 

A double fracture, or a simultaneous fracture, occurring in both 
clavicles, seldom occurs. I have recorded two cases {four fractures, 
three of which are incomplete), both occurring in young boys. 4 

Malgaigne says it has only happened to him to see it once in 2,358 
cases, at the Hotel Dieu, and he can recollect only five other examples. 
And of 158 cases of broken clavicles reported from the New York 
Hospital, it is stated to have occurred in only four. These gentlemen, 
however, only report hospital cases, and they have reference, doubt- 
less, to complete fractures ; while double fractures, according to my 
experience, occur more often in children than in adults, and are of the 
character of partial fractures, without usually much displacement; 
which facts, if sustained by subsequent observations, would sufficiently 
explain their infrequency in hos- 
pital, and their relative frequency 
in private experience. 

Symptoms. — In all cases of 
complete fracture with displace- 
ment, no difficulty will be ex- 
perienced in deciding upon the 
nature of the injury. 

The patient is found generally 
leaning toward the injured side, 
while the opposite hand sustains 
the elbow of the same side, to 
prevent its dragging downwards. 

The shoulder falls downwards, 
forwards, and inwards ; while, at 
the same time, the line of the 
bone is interrupted by the sharp 
and projecting point of the ster- 
nal fragment. 

If the fracture is the result of 
a direct blow, a swelling and dis- 
coloration may be seen at the seat of fracture, but if it is the result of 



Fig. 41. 




Complete Fracture.— Oblique ; at outer end of the 
inner two-thirds. (From nature.) 



1 London Med. Gaz., vol. ii. p. 382. 2 New York Med Times, March 16, 1861. 

3 Lente, N. Y. Journ. of Med., July, 1850. * Rep. on Def. after Frac, Cases 5, 6, 10. 



184 FKACTURES OF THE CLAVICLE. 

a counter stroke, we must look to the top or point of the shoulder for 
the signs of a contusion. 

The patient also experiences pain when an attempt is made to raise 
the arm at a right angle with the body, and especially in attempting 
to carry the arm across the body, by which the ends of the broken 
clavicle are driven into the flesh. In two cases (Cases 19 and 50 of 
my Report on Deformities) of oblique fracture, accompanied with dis- 
placement, occurring in the middle third of the bone, I have particu- 
larly noticed that the patients could easily lift the hands to the head, 
and in one of these cases the patient, a boy, fourteen years old, raised 
his arm perpendicularly over his head. Such exceptions are not very 
uncommon. 

Crepitus can be detected sometimes by simply pressing down the 
sternal fragment, but it is almost always present when we draw the 
shoulders forcibly back, so as to bring the broken fragments into more 
perfect contact. 

If there is no displacement, still crepitus may generally be discovered 
by grasping the bone between the thumb and fingers, and moving it 
gently up and down, or by slight pressure upon the point of fracture. 

"When the fracture occurs close to the acromial extremity, external 
to the coraco-clavicular ligaments, although, according to Robert 
Smith, there is usually considerable derangement, yet it is not accom 
panied with a corresponding amount of external deformity, and its 
diagnosis will require, therefore, more care and attention on the part 
of the surgeon. 

Prognosis in this fracture deserves especial attention. In no other 
bone, except the femur, does a shortening so uniformly result. Of 
seventy-two complete fractures only sixteen united without shortening; 
and of twenty-seven simple, oblique, complete fractures, which occurred 
at or near the outer end of the middle third, only one united without 
shortening (Case 46 of my Report), and in this case the patient was 
but fifteen years old, and the fragments were never much displaced ; 
nor can I say that the treatment, a board across the back after the 
manner of Keckerley, had anything to do with the result. Six cases 
of complete transverse fracture, occurring at the same point, united 
Avithout shortening. 

The shortening varies from one-quarter of an inch to one inch, or 
more, and the fragments are almost always, especially when the frac- 
ture is through the middle third, found lying in the position in which 
we have described them to be at the first — the outer end of the inner 
fragment being above, and often a little in front of the outer : some- 
times, especially in lean persons, and when the fracture is very oblique, 
presenting a sharp and unseemly projection. 

The greatest amount of shortening is generally found in those frac- 
tures which occur through the middle third ; in fractures near the 
sternal end there is usually very little permanent displacement ; the 
same is true when the fracture is at the acromial end, and between 
the coraco-clavicular ligaments, as the observations of Robert Smith, 
already quoted, have sufficiently established ; but if the fracture is 



FKACTUKES OF THE CLAVICLE. 



185 



beyond these ligaments, the final displacement and deformity may be 



very great. 



The presence of a small amount of ensheathing callus soon after 
the cure is completed, sometimes increases the deformity. It is rarely 
seen to encircle the bone completely, and occasionally it appears to 
be most abundant in the direction of the salient points of the fracture, 
that is, above and below; so that, unless the examination is made with 
care, the projecting points of callus which remain, sometimes after 
many years, may be easily mistaken for an intercepted fragment turned 
at right angles to the axis of the bone. In the case of partial fracture, 
reported by Dr. Green, a similar circumstance was observed, which his 
natural shrewdness soon enabled him to explain. 1 

Eobert Smith has observed also, that in cases of fracture external 
to the conoid ligament, osseous matter is freely formed upon the under 
surface of each fragment, but there is seldom any deposited upon the 
upper surface of either. These osseous growths, occupying the situa- 
tion of the coraco-clavicular ligaments, frequently prolong themselves 
as far as the coracoid process, and in some cases to. the notch of the 
scapula. Still less frequently these osteophytes become fused with the 
coracoid process, and a true anchylosis exists. 

In comminuted fractures the intercepted fragments generally fall 
off from the line of the other fragments, and cannot easily be restored. 

The clavicle being a spongy and vascular bone, usually unites with 
great rapidity, generally within twenty days. In the fourth example 
of transverse fracture already men- 
tioned as having been seen by me, 
the union seemed to be tolerably 
firm in seven days. Wallace re- 
ports one case from the Pennsyl- 
vania Hospital, which was cured 
in eight days, and another in nine 
days. 2 Veipeau says the clavicle 
will unite in from fifteen to twenty- 
five days; Benjamin Bell, in four- 
teen ; Stephen Smith has seen it 
firm in fifteen days. 

Whatever may be the degree of 
displacement, or the condition of 
the system, unless in a case of gun- 
shot fracture, it is very seldom that 
it refuses to unite altogether, or that 
the union is ligamentous : and in 
the few cases found upon record of 
a ligamentous union, the functions 
of the arm do not seem to have suffered any serious ultimate injury, 
as the following example will illustrate : — 

Edmund Nugent, a stout Irish laborer, now twenty-five years old,. 



Fig. 42. 




Comminuted Fracture. — United, 
ture.) 



(From na 



1 Trans, of Amer. Med. Assoc, for 1855, Case 13 of Frac. of Clavicle. 

2 Am. Journ. Med. Sci., vol. xvi. p. 115. 

13 



186. FKACTUKES OF THE CLAVICLE. 

was received into the Buffalo Hospital of the Sisters of Charity, in 
March, 1854. He states that, several years before, he fell from a horse 
and broke his left clavicle, at the outer end of the middle third. This 
was near Cork, in Ireland, and without consulting any surgeon or 
"handy man," he continued at work, holding the tail of the plough, 
nor from that day forward did he employ a surgeon, or dress his arm, 
or cease from his work. 

The clavicle presents now the same deformity which nearly all other 
similar fractures present after what is usually termed successful treat- 
ment, except that it is not united by bone. The outer end of the inner 
fragment rides upon the inner end of the outer fragment half an inch. 
The ligament uniting the two extremities is so long and firm that it 
can be distinctly felt, and the fragments may be moved upon each 
other with great freedom. 

In order that we might determine the amount of injury which he 
had suffered from the ligamentous union, we directed him to lift weights 
placed on a table before him, while he was seated upon a chair. We 
ascertained from this experiment that with his left arm he could lift 
as much, within three ounces, as he could with his right, and he was 
not himself conscious of any difference. The muscles of the left arm 
seemed as well developed as those of the right. 

Chelius also refers to two cases mentioned by Gurdy and Yelpeau, 
in which, although an artificial joint remained, the use of the limb was 
but little impaired. 1 

In a case of compound and comminuted gunshot fracture reported 
by Ayres, of New York, the recovery was remarkable. The man was 
sixty -two years old, and in excellent health when the injury was 
received. The clavicle was so extensively comminuted that before 
the wound closed over one-third of the bone had escaped, and yet at 
the end of one year from the time of the accident the shoulder was 
perfectly symmetrical with its fellow, without drooping or falling 
forwards. Dr. Ayres thinks that all of the clavicle which was lost 
has been reproduced. 

A partial paralysis, with atrophy of the muscles of the arm, accom- 
panied, also, with more or less rigidity and contraction of the muscles, 
both of the arm and forearm, is, according to my observation, a more 
frequent result of these fractures. 

Mr. Earle has recorded a case of comminuted fracture of the clavicle, 
in which the nerves converging to form the axillary plexus were so 
much injured that paralysis of the arm ensued; and it was noticed as 
an interesting fact, that the patient could not afterwards put her hand 
into even moderately warm water without the effects of a scald being 
produced, characterized by vesications, redness, etc. 2 

Desault saw a case at Hotel Dieu, in which, although the clavicle 
was not broken, the force of the blow upon the clavicle was sufficient 
to produce a severe concussion of the brachial plexus, and paralysis 
of the arm. A timber had fallen from a building, striking upon the 

1 Chelius, Arnpr. ed., vol. i. p. 603. 

2 S. Cooper's First Lines, fourth Arner. ed., vol. ii. p. 323. 



FRACTURES OF THE CLAVICLE. 187 

external part of the left clavicle. A considerable wound, followed by 
swelling, pointed out the place on which the blow had been received. 
No apparatus was applied, and on the third day a numbness and par- 
tial loss of the power of motion occurred in the arm of the affected 
side. Soon afterward an insensibility came on, and by the seventh 
day the paralysis of the arm was complete. It was not until after a 
tedious treatment that the limb recovered in part its original strength. 1 

In Case 23 of my report to the American Medical Association, which 
was followed by paralysis of the opposite arm, and spinal curvature, 
these results were probably due to some injury of the back received 
at the time of the accident ; but one cannot avoid, a suspicion that the 
apparatus, Brasdor's jacket, contributed somewhat to the unfortunate 
result. No axillary pad was employed, but the straps over each, 
shoulder were buckled so tight that he was compelled to incline his 
head constantly to the right side. He was unable to lie down, and 
could only recline in a half sitting posture. This treatment was con- 
tinued four weeks ; and two months after its removal the paralysis 
and spinal distortion commenced. 

In Case 38, also, of the same report, a comminuted fracture, paralysis 
with contraction of the muscles extending to the wrist and fingers, ex- 
isted, but whether it was due to the severity of the original injury or 
to the treatment, could not be satisfactorily ascertained. 

Gibson relates a remarkable instance of this kind. A young man 
was struck on the clavicle by the falling limb of a tree, breaking it into 
numerous pieces, and bruising the parts so severely as to give rise to 
violent inflammation. " The fragments had been driven behind and 
beneath the level of the first rib, and so compressed the plexus of 
nerves as to wedge them into each other, and by the subsequent in- 
flammation to blend them inseparably together. Complete paralysis 
and atrophy of the whole arm ensued, and the patient's object in visit- 
ing Philadelphia was to submit to an operation, in hopes of elevating 
the clavicle to its natural height, and taking off pressure from the 
nerves." Dr. Gibson, however, did not believe that the prospect of 
success was sufficient to warrant the operation, and the young man 
was sent home. 2 

It will not do to deny, therefore, the possibility of a paralysis as 
resulting from a concussion of the axillary nerves, produced by a blow 
upon the clavicle, nor of a paralysis resulting from a direct injury in- 
flicted by the points of the fragments upon this plexus in certain very 
badly comminuted fractures ; but it is certain that these conditions 
will not satisfactorily explain all of the examples in which paralysis 
has followed simple fractures. In some cases it is no doubt due rather 
to the injudicious mode of using an axillary pad, by means of which 
the arm is converted into a powerful lever, and thus the brachial 
nerves are made to suffer from compression along the inner side of the 
arm itself. In short, it must be confessed that it is sometimes due to 
the treatment alone, and not to the original injury. 

! Desault on Frac. and Disloc, Amer. ed., p. 14, 1805. 
2 Gibson, op. cit., 6th ed. vol. i. p. 271. 



188 FKACTUKES OF THE CLAVICLE. 

Parker, of New York, in a note to the edition of S. Cooper's Sur- 
gery, just quoted, declares that he has seen one patient who had lost 
the use of his arm from the pressure upon the nerves by the wedge- 
shaped pad, over which the limb was confined, in order to pry the 
shoulder outwards. Stephen Smith mentions a case of partial para- 
lysis from the same cause. 1 

A similar c^se has come under my own observation. A lady, aged 
fifty-one years, was thrown from her carriage, breaking the right 
clavicle obliquely at the outer end of the middle third. During the 
first three weeks the arm was dressed with Fox's apparatus, which 
was at no time particularly painful. She was then placed under the 
care of another surgeon, who finding the fragments overlapped, ap- 
plied very firmly a figure-of-8 bandage, with an axillary pad, securing 
the arm snugly to the side of the body ; hoping by these means to 
restore the fragments to their place. The pain which followed was 
excessive, and notwithstanding the free use of anodynes, it became so 
insupportable that at the end of fourteen hours the dressings were 
removed by another surgeon, and Fox's apparatus again substituted. 
These were also applied much more tightly than at first, and during 
the four weeks longer that they remained on, repeated attempts were 
made to reduce the fragments. 

Forty-eight days after the accident, she consulted me. The clavicle 
was then united, and overlapped half an inch. The whole arm was 
swollen, painful, and very tender, with total inability to move it. 

I removed all the dressings, and, during the time she remained 
under my care, in a private room at the hospital, there was a gradual 
improvement in the condition of her arm, in respect to swelling and 
tenderness, but the paralysis did not much abate. 

Erichsen thinks he has seen one case of comminuted fracture, pro- 
duced by a direct blow, in which the subclavian artery was ruptured ; 
great extravasation of blood resulted, and the arm was threatened 
with gangrene. The patient having recovered, however, the diagnosis 
could not be determined by actual dissection. 2 

Since among surgeons some difference of opinion seems to exist as 
to the practicability of overcoming the displacement in certain frac- 
tures of the clavicle, it is proper that I should defend the accuracy of 
my own observations by a reference to the observations of others. 

In nine of eleven cases reported by Stephen Smith, one of the 
surgeons at Bellevue Hospital, New York, more or less deformity 
remained after the cure was completed. In the two remaining cases 
the actual results are unknown. 3 

Chelius remarks : " Setting of this fracture is easy, yet only in very 
rare cases is the cure possible without any deformity." * * * * 
" It is considered, also, that the close union of the fracture of the collar 
bone depends less on the apparatus than on the position and direction 
of the fracture ; (therefore, in spite of the most careful application of 

1 New York Journ. of Medicine, May, 1857. 

2 Erichsen, Surgery, Amer. ed., p. 205. 

3 New York Journ. Med., May, 1857, p. 382. 



FRACTURES OF THE CLAVICLE. 



189 




this apparatus, some deformity often re- Fi s- 43. 

mains.") 1 

Velpean, in a lecture given in 1846, 
and published in the Gazette des Hdpi- 
taux, declares that with all the bandages 
imaginable in the case of an oblique 
fracture at the junction of the outer 
third with the inner two thirds we can- 
not prevent deformity. 

Vidal observes: "Fracture of the 
clavicle is almost always followed by 
deformity, whatever may be the perfec- 
tion of the apparatus and the care of 
the surgeon." 2 

" Hippocrates has observed that some 
degree of deformity almost always ac- 
companies the reunion of a fractured 
clavicle; all writers since his time have 
made the same remark ; experience has 
confirmed the truth of it." 3 

Turner remarks as follows: "As to 
the reduction of this fracture, it must 
be owned the same is often easier re- 
placed than retained in its place after it is reduced ; for its office being 
principally to keep the head of the scapula, or shoulder, to which, at 
one end, it is articulate, from approaching too near, or falling in upon 
the sternum, or breast bone, it happens that, on every motion of the 
arm, unless great care be taken, the clavicle therewith rising and 
sinking, the fractured parts are apt to be distorted thereby. Besides, 
even in the common respiration, the costse and sternum aforesaid, 
where the other end of this bone is adnected, together with the motion 
of the diaphragm, rising and falling, especially if the same be extra- 
ordinary, as in coughing and sneezing, are able to undo your work, 
not to mention the situation thereof, less capable of being so well 
secured by bandage as many others. All which, duly considered, it 
is no wonder that upon many of these accidents, although great care 
has been taken, these bones are sometimes found to ride, and a pro- 
tuberance is left behind, to the great regret particularly of the female 
sex, whose necks lie more exposed, and where no small grace or 
comeliness is usually placed." 4 

Says Johannis de Gorter: "Eestituiter facile tractis humeris a 
ministro posterius, dum simul suo genu locato ad spinam dorsi, dor- 
sum sustentet minister, nam tunc chirurgus fobs digitis claviculam 



Velpeau's dextrine bandage; no axil- 
lary pad. 



1 System of Surgery. By J. M. Chelius, of Heidelberg, with notes by South. First 
Amer. ed., vol. i. pp. 603, 605. 

1 Vidal (de Cassis), Paris ed., vol. ii. p. 105. 

3 Treatise on Fractures and Luxations. By J. P. Desault. Edited by Xav. Bichat, 
and translated by Charles Caldwell, M. D. Philadelphia, 1805, p. 9. 

1 The Art of Surgery, by Daniel Turner, vol. ii. p. 256. London ed., 1742. 



190 FRACTURES OF THE CLAVICLE. 

fractam reponere potest. Difficilius autem in reposita sede retinetur, 
sed loca cava supra et infra claviculam spleniis implenda." 1 

Says Heister, writing only a little later : " The reduction of a broken 
clavicle is not very hard to be effected, especially when the fracture is 
transverse : nor is it unusual for the humerus, with the fragment of 
the clavicle, to be so far distorted as not to be easily replaced with 
the fingers ; but the difficulty is much greater to keep the bone in its 
place when the fracture is once reduced, especially if the bone was broken 
obliquely." 2 

Amesbury, after having exposed the inefficacy of all previous modes 
of dressing, and especially of the figure-of-8 bandage, Desault's, Boyer's, 
and an apparatus recommended by Sir Astley Cooper, proceeds to 
describe his own apparatus and to affirm its excellence. It is, how- 
ever, not much unlike a multitude of others, and is liable to the same 
objections. 3 

M. Mayor, of Lausanne, thinks that up to this day no successful 
mode of treatment has been devised. " Here everything appears as 
yet so little determined that each day sees some new propositions and 
different procedures," etc. He believes, however, that in his simple 
handkerchief bandage, with straps across each shoulder, the indica- 
tions are most fully accomplished and the most successful results are 
obtained. If, however, it were to be treated without apparatus, the 
horizontal position, lying upon the back, would, in the end, make the 
most perfect unions. 4 

Says M. Malgaigne : " The prognosis, considering the trivial cha- 
racter of this fracture, is sufficiently difficult. For, little as may be 
the displacement, the surgeon ought not to promise a reunion without 
deformity ; and certain successful results, proclaimed from time to 
time, betray, on the part of those who relate them, the most extrava- 
gant exaggerations." 3 

M. Kelaton having spoken of the various plans which have been 
suggested to retain this bone in place, and of their inefficiency, comes 
at last to speak of the handkerchief bandage of M. Mayor, and re- 
marks : — 

" This apparel is very simple ; but neither will it remedy the over- 
lapping." **'*.* -<«Of all the apparels which we have passed 
in review, there is, then, not one which fills completely the three indi- 
cations usually present in the fracture of a clavicle. None of them 
oppose the displacement ; they have no effect, with whatever care 
they may be applied, but to maintain immobility in the limb. We 
think, then, that it is useless to fatigue the patient with an apparatus 
annoying, and perhaps, even painful : a simple sling, secured upon 
the sound shoulder, will be sufficiently severe. Nevertheless, as this 

1 Johannis de Gorter ; Chirurgia Repurgata, p. 79. Lugduni Batavorum, 1742. 

2 Heister's Surgery, vol. i. p. 134. London ed., 1768. 

3 Treatment of Fractures, by Joseph. Amesbury, vol. ii. p. 527. London ed., 1831. 
* Nouveau Systeme de Deligation Chirurgicale, par Matliias Mayor, de Lausaune 

p. 384, etc.: (also Atlas, plate 3. fig. 23.) Paris edit., 1833. 

5 Traite des Fractures et des Luxations, par J. F. Malgaigne, tome premier, p. 473, 
Paris ed., 1847. 



FRACTURES OF THE CLAVICLE. 191 

does not assure so complete immobility as the bandage of M. Mayor, 
it is to this that we think the preference ought to be given in all cases 
of fractures of the clavicle, whether accompanied with displacement 
or not, whether they occupy the middle or the external part of the 
clavicle. If the fracture presents no displacement, we shall obtain a 
cure which will leave nothing to be desired. If there is a tendency to 
displacement, the consolidation will be effected with a deformity more 
or less marked ; but since this deformity is inevitable, at least with 
adults, whatever may be the apparel which we employ, it is evident 
that the apparatus which causes the least constraint ought to have the 
preference. We may remark, farther, that this union with deformity in 
nowise impairs the free exercise of all the movements of the member." 1 

"The venerable gentleman who stands at the head of American 
surgery, and whose manipulations with the roller approach very 
nearly to the limits of perfection, informed us, in 1824, that he had 
never seen a case of fractured clavicle cured by any apparatus, with- 
out obvious deformity." 2 

I need not say that the " venerable gentleman" to whom Dr. Coates 
refers in this passage, was the late Dr. Physick, of Philadelphia. 

Dr. Gross says that according to his experience "fractures of the 
clavicle are seldom cured without more or less deformity, whatever 
pains may be taken to accomplish the object." 3 

Treatment. — If evidence were needed beyond that which has been 
furnished, of the difficulty of bringing to a successful issue the treat- 
ment of this fracture, it might be supplied, one would think, by a 
reference merely to the immense number of contrivances which have 
been at one time and another recommended. 

A catalogue of the names only of the men who have, upon this 
single point, exercised their ingenuity, would be formidable, nor 
would it present any mean array of talent and of practical skill. 

All these surgeons, however, have admitted the same indications of 
treatment, viz., that in order to a complete restoration of the outer 
fragment, which alone is supposed to be much displaced, we are to 
carry the shoulder upwards, outwards, and backwards. But as to 
the means by which these indications can be most easily, if at all, ac- 
complished, the widest differences of opinion have prevailed ; and, in 
the debate, it may be seen that, while on the one hand no invention 
has wanted for both advocates and admirers, on the other hand, no 
method has escaped its equivalent of censure. 

Hippocrates, Celsus, Dupuytren, Flaubert, Lizars, Pelletan, and 
others, directed the patients to lie upon -their backs, with little or no 
apparatus, but generally with the spinal column so supported and 
lifted with pillows, as that the shoulders would by their own weight 
fall backwards. S. Cooper and Dorsey also recommend that the 

1 Elemens de Pathologie Chirurgicale, par A. Nelaton, tome premier, p. 720, Paris 
ed., 1844. 

2 Reynal Coates, Amer. Med. Journ., vol. xviii. p. 62, old series. It is probable that 
Dr. Physick here referred to complete and oblique fractures of the middle third, or 
that Dr. Coates has forgotten the precise language employed on this occasion. 

3 Gross, System of Surgery, vol. ii. p. 155, 1859. 



192 FKACTUKES OF THE CLAVICLE. 

patients should be confined in this position during most of the treat- 
ment ; and from the account given by Dr. Lente, it will be understood 
that a similar plan is generally adopted in the New York City Hos- 
pital. "But this result (deformity) rarely happens when the patient 
has strictly followed the directions of the surgeon, as to position espe- 
cially, for it is by position more than by any other remedial means, 
that a good result is to be effected. * * * * * The persevering 
continuance of the supine position in bed, with the head low, and, if 
necessary, a pad between the shoulders. This is the treatment uni- 
formly adopted by Dr. Buck, in the hospital, and the results of his 
treatment are certainly such as to recommend it highly." 

Nearly the same method we find recommended by Alfred Post, in 
1840, then one of the surgeons of that hospital; the arm being merely 
kept in a sling and bound to the side, with the patient lying upon his 
back. Dr. Post mentions a case treated in this manner, which termi- 
nated with very little deformity ; l and I have my self treated many cases 
by this plan with more than average success. 

Jan. 2, 1856. — Mary Ann S., set. 24, fell down a flight of stairs, 
breaking the right collar bone obliquely near its middle. She was 
unwilling to submit to bandages, and I directed her simply to lie 
upon her back in bed. On the fourteenth day the fragments had 
united; and at the end of the third week I dismissed her with an over- 
lapping of the fragments of less than half an inch, and with scarcely 
any perceptible deformity. 

Alexander Mooney, ast. 33, was admitted to the Buffalo Hospital, 
December 3, 1856, with an oblique fracture of the left clavicle, at the 
outer end of the middle third. On measurement we found the frag- 
ments overlapped nearly half an inch. 

In presence of a class of medical students I applied Bartlett's appa- 
ratus, a very convenient form of the sling dressing, and the same 
which has been much employed at the Mass. General Hospital, in Bos- 
ton. On the following day the apparatus was found to be loose, and 
it was carefully retightened. On the third and fourth days, also, it 
was found necessary to readjust it more or less, and the fragments of 
the broken clavicle continued to overlap. 

On the fifth day Bartlett's apparatus was removed, and the patient 
laid upon his back in bed, with his arm simply tied to the side of his 
body by a few turns of a roller. 

On the tenth day all motion had ceased between the fragments ; but 
he was kept in bed three weeks. 

Jan. 10, 1857, he was discharged from the hospital, with an over- 
lapping of only about one-quarter of an inch, and with scarcely any 
perceptible deformity. 

Dr. Eve, of Nashville, Tenn., and Dr. Eastman, of Broome County, 
N. Y., have also employed this method successfully; 2 while Malgaigne 
declares it to be the most reliable means of obtaining an exact union. 

i N. Y. Journ. of Mp<L, vol. ii. p. 226. 

2 Bost. Med. and Surg. Journ., vol. lvi. p. 468. 



FRACTURES OF THE CLAVICLE. 



193 




Albucasis, Lanfranc, Guy de Chauliac, Petit, Parr, Syme, Skey, Brun- 
ninghausen, Parker, and very many 
others, especially among the English, Fi §- 44 - 

have preferred in order to carry the 
shoulders back, a figure-of-8, while 
Desault, Colles, South, and Samuel 
Cooper, have represented this bandage 
as useless, annoying, and mischievous. 

Heister, Chelius, Miller, Breffield, 
Keckerly, 1 Coleman, 2 Hunton, 3 prefer, 
for this purpose, some form of back- 
splint, extending from acromion to 
acromion, against which the shoulders 
may be properly secured. Parker 
says that splints of this kind, with a 
figure-of-8 bandage, are "better than 
all the apparatus ever invented," 
while Mr. South gives his testimony 
in relation to all dressings of this pigure-of-s. 

sort, as follows : " I do not like any 

of the apparatus in which the shoulders are drawn back by bandages, 
as these invariably annoy the patient, often cause excoriation, and 
are never kept long in place, the person continually wriggling them 
off to relieve himself of the pressure." 

Fox, 4 Brown, 5 Desault, and others bring the elbow a little forwards, 
and then lift the shoulder upwards and backwards. Wattman and 
Lonsdale carry the elbow still further forwards, so as to lay the hand 
across the opposite shoulder, while Guillou carries the hand and fore- 
arm behind the patient, and then proceeds to lift the shoulder to its 
place. 

Thus Desault, Fox, and Wattman accomplish the indication to carry 
the shoulder back, by lifting the humerus while the elbow is in front 
of the body, and Guillou accomplishes the same indication by lifting 
the humerus when the elbow is a little behind the body. Chelius also 
says : "The elbow, as far as possible, is to be laid backwards on the 
body." 

Sargent, who believes that with Fox's apparatus " the occurrence of 
deformity is the exception," and not the rule, and prefers it to all 
others, has treated three cases by Guillou's method, and is perfectly 
satisfied with its operation. Hollings worth, of Philadelphia, has also 
treated one case successfully by Guillou's method, and adds his testi- 
mony in its favor. 

But how shall we explain these equal results from opposite modes 
of treatment ? Is the indication to carry the shoulders back, which 



1 Keckerly, Amer. Journ. Med. Sci., vol. xv. p. 115 ; also, my Report on Deformi- 
ties after Fractures, in Trans, of Amer. Med. Assoc, vol. viii. p. 440. 

2 Coleman, New York Journ. Med., second series, vol. iii. p. 274, from New Jersey 
Med. Rep. 

3 Hunton, ibid. ; also, New Jersey Med. Rep., vol. v. p. 146. 

4 Fox, Liston's Practical Surgery, Amer. ed., p. 47. 
6 Brown, Sargent's Minor Surgery, p. 132. 



19± 



FRACTURES OF THE CLAVICLE 



Fox sought to accomplish by pressing the elbow upwards and back- 
wards, as easily attained by pressing the elbow upwards and forwards ? 

Fig. 45. 




I'd 



11 



E. C. Kecseelt's Apparatus. — "The upper figure exhibits a front view, and the lower a hack view of 
the splint, a, a. Are two bandages with buckles attached to one end of each, bb, bb. Are four mortised 
holes for the passage of the two bandages, a, a. c A portion of the splint padded, to prevent its bruising 
the patient, d, d. Two loops of leather, tacked on the back of the splint, for the passage of the bandages, 
where the mortised holes are too far apart for the breadth of the patient from shoulder to shoulder. 

' ' Mode of Application. — The end of the splint corresponding to the uninjured side is to be pressed close 
to the back of the shoulder, and retained so by drawing the bandage tight, and retaining it by means of 
the bnckle. Previous to fixing the bandage, it should be passed through two loops on a small pad. which 
is to be placed in the axilla. This pad is used for the purpose of preventing the cutting of the bandage. 
After passing the other bandage through two loops, on a large, cuneiform pad, which is placed in the 
axilla of the injured side, it is drawn sufficiently right and secured by the buckle. The last thing to be 
done is to place the handkerchief, doubled into a triangular form, in such a manner over the arm. the 
front and back parts of the thorax, as that it shall draw and confine the arm of the injured side close to 
the body, give it support, and prevent its falling down ' ' 

Or are we not compelled to infer that there has been some mistake as 
to the precise amount of good accomplished by the apparatus in 
either case ? Moreover. Coates, 1 Keal, and others instruct us that the 
only safe and proper position for the humerus is in a line with the 
side of the body, and that it must neither be carried forwards nor 
backwards. 

Paulus ^Egineta. Boyer, Desault, Pecceti. Liston, Fergusson. Samuel 
Cooper, Erichsen, Miller, Skey, Levis, Dorsey, 2 Gibson, 3 Fox, H. 
H. Smith, 4 Xorris. 5 Sargent. Eastman, 5 recommend an axillary pad, 
while Eicherand, Yelpeau, Dupuvtren. Benjamin Bell, Syme, deny its 
utility, or affirm its danger. Dr. Parker has seen one patient in whom 
paralysis of the arm resulted from the pressure upon the brachial 
nerves, in the attempt " to pry the shoulder out ;" and I have myself 
recorded another. 

Cabot, of Boston. Massachusetts, has recommended a mould of gutta 
percha laid over the front and top of the chest. 7 

Desault's plan, which took its origin, as Yelpeau thinks, in the 



1 Coates. Amer. Journ. Med. Sci., vol. xviii. p. 62. 

2 Dorsey, Elements of Surgery, vol. i. p. 133. 

s Gibson. Institutes and Practice of Surgery, vol. i. p. 271. 

4 H. H. Smith. Practice of Surgery, p. 354. 

5 Xorris. Liston's Practical Surg.. Amer. ed.. p. 46. 

6 Eastman. Apparatus for Fractured Clavicle, by Paul Eastman, Aurora. 111. ; Bos- 
ton Med. and Surg. Journ.. vol. xxiii. p. 179. 

: Cabot, Bost. Med. and Surg. Journ., vol. lii. p. 232. 



FEACTURES OF THE CLAVICLE. 



195 



Fig. 46. 



spica of Glaucius, under various modifications, is recommended by 
Delpech, Cruveilhier, Lasere, Flamant, Samuel Cooper, Fergusson, 
Liston, Cutler, Physick, Dorsey, Coates, and Gibson ; while by Yel- 
peau, Syme, Colles, Chelius, Samuel Cooper, and Parker, it is regarded 
as inefficient and troublesome. Says Mr. Cooper : " In this country, 
many surgeons prefer Desault's bandages, but I do not regard them 
as meeting the indications, and consider them worse than useless." 

The dextrine bandages, or apparatus immobile, of Blandin, Yelpeau, 
and others, constitute only another form of the bandage dressing of 
Desault. In this connection it ought to be noticed that Yelpeau does 
not regard the employment of this apparatus, or of any other demanding 
great restraint, as imperative. In his great work on anatomy, re- 
ferring to the fact that when the bone is broken and overlapped, the 
patient is still able, in many cases, to move the arm freely, he re- 
marks: "Do not these cases give support to the opinion of those who 
admit that fractures of the clavicle do not actually require any other 
apparatus than the simple supporting bandage ?" " It is necessary to 
observe," he adds, " that by thus acting we do not prevent an over- 
lapping," 1 etc. 

The sling, in some of its forms, is 
employed by Eicherand, Huberthal, 
Colles, Miller, Fox, Stephen Smith, 2 H. 
H. Smith, Bartlett, 3 Levis, 4 Dugas, 5 Ben- 
jamin Bell, Bransby Cooper, Earle, 
Chapman, Keal, and by a large majority 
of the English surgeons ; while Dr. 
Gibson declares the sliog bandage, em- 
ployed so much by the English, "the 
most inefficient, contemptible, and inju- 
rious of all contrivances for such pur- 
poses." 

No apparatus, perhaps, has been so 
generally employed, among American 
surgeons, as that form of the sling in- 
troduced by Dr. George Fox into the 
Pennsylvania Hospital in 1828. 

Sargent says of it : " Fractures of the 
clavicles, treated by this apparatus, are 
daily dismissed from the Pennsylvania 
Hospital, and by surgeons in private * b T , ^ „ F 

r . ' i-i Mii axillary pad, roll a strip of woollen 

practice, CUred Without perceptible de- flannel, four or five inches wide, around 
formity." tne axillary strap, to the size required. 

Norris, in a note to Listeria Practical Th „ e fPP aratus raa ^ be used for either 

cy nr> it j u ,i i • r> • t slde "7 changing the attachment of the 

Surgery, affirms that the chief mdica- s i ing .» (Bartlett.) 




1 Velpeau, Anatomy, Atner. ed., vol. i. p. 242. 

2 Stephen Smith, New York Journ. Med., vol. ii. 3d series, p. 384 (May, 1857). 

3 Bartlett, My " Report on Defor.," etc., Appendix ; also Bost. Med. and Surg. Journ., 
vol. Ii. p. 404. 

4 Levis, H. H. Smith's Practice of Surg., p. 365. Am. Journ. Med. Sci., April, 
1860, p. 428. 

5 Dugas, Report on Surgery. 



196 



FRACTURES OF THE CLAVICLE 



Fig. 47. 



tions in the treatment of fracture of the clavicle are perfectly fulfilled 
by the use of this apparatus." 

H. H. Smith, in his Minor Surgery, declares that Fox's apparatus 
accomplishes "perfect cures" in very many cases, and that it is "a 
very rare thing for a simple case to go out of the house (Pennsyl- 
vania Hospital) with any other deformity save that which time cures, 
viz., the deposition of the provisional callus." He has also repeated 
substantially the same opinion in his larger work entitled Practice of 
Surgery. 

_ Such testimony in favor of any dressing demands respectful atten- 
tion ; and I shall not be regarded as detracting from the respect due 
to these authorities, when I express my belief that it is in deference to 
the distinguished reputation of the surgeons who have during the last 
thirty years had charge of the services in that hospital, and who have 
been so loud in its praise, that the use of this apparatus has, with us, 
become so general. I believe, also, that, in some measure, this gene- 
ral preference is due fairly to the intrinsic excellence of the dressing. 

But I must be permitted to express a 
doubt whether it has made deformities of 
the clavicle "the exception, instead of the 
rule," with us. I have used this dressing 
oftener than any other form, and yet my 
success has by no means been so flattering 
as has been the success of these gentle- 
men. I have seen others employ it, 
also, and with pretty much the same re- 
sult. Nor ought it to be forgotten that, 
in Great Britain, by far the greater ma- 
jority of surgeons employ an apparatus 
essentially the same. I have seen it in 
many of the hospitals, and Mr. Bicker- 
steth, one of the surgeons of the Liver- 
pool Infirmary, informed me, in 1844, 
that it had been in use with them as long 
as thirty years. All that has justly been 
said against the English mode of dress- 
ing by slings, is equally true of this; and 
whatever has been affirmed of the danger 
of using an axillary pad applies as much 
to this as to any other mode of using 
the same. 

I believe, however, that in the Penn- 
sylvania Hospital, the axillary pad em- 
ployed is not so large, and especially, 
not so thick, as that recommended by 
Desault, and in this respect it is plainly 
an improvement; but then, in the same 
proportion that it is made less thick, it 
is less powerful to accomplish the indication in question; and if it 




George Fox's Apparatus "consists of a 
firmly stuffed pad of wedge shape, and 
about half as long as the humerus, hav- 
ing a band attached to each extremity of 
its upper or thickest margin ; a sling to 
suspend the elbow and forearm, made of 
strong muslin, with a cord attached to 
the humeral extremity, and another to 
each end of the carpal portion ; and a 
ring made of muslin stuffed with cotton 
to encircle the sound shoulder, and serve 
as means of acting upon and receiving 
the sling." (Sargent.) 



FKACTUKES OF THE CLAVICLE. 197 

merely fills the axillary space, then it is no longer a fulcrum upon 
which the arm is to operate as a lever. 

Kegarding, then, the importance of this question to the interests of 
surgery, and observing the wide differences of opinion which are 
entertained here and elsewhere as to the real value of this dressing, 
is it asking too much of these gentlemen that they will present ns 
some more precise statistical testimony? It will be observed that its 
advocates claim for it what is not to-day, at least, claimed for any 
other apparatus, viz : that, nnder its use in the Pennsylvania Hos- 
pital, and in the hands of private practitioners, so far as they have 
seen, deformities have become the " exception. It is affirmed to an- 
swer "perfectly" all the indications. By which it must be intended 
to say, that, in addition to both of the other indications, that also, 
which has always heretofore been found so difficult, if not impossible, 
the carrying out of the shoulder, is in a majority of cases perfectly 
accomplished — the clavicles are not shortened. 

If it is intended, however, to say that a shortening is not generally 
prevented, bnt only that no unseemly projection of the fractured ends 
will be fonnd to result, I reply, that then it does not answer all the 
indications; and I beg, further, to suggest that the avoidance of an 
upward projection seems to me to depend much more upon that part 
of any apparatus which lifts the shoulder, and which belongs to a 
multitude of other forms of dressing as well as to that in question, 
than upon that which forces the shoulder out, and it may be accom- 
plished, in a majority of cases, as well without an axillary pad, with 
a mere sling, as with it. But, in fact, my experience has convinced 
me that the absence or presence of such a projection, after union, is 
due much to the circumstances of the fracture, as to whether it is 
more or less oblique ; and still more especially, to the degree of round- 
ness or emaciation of the patient, rather than to any form, or part, or 
condition of the apparatus. It will be found more distinct in oblique 
fractures than in transverse, and much more marked in thin persons 
than in plump, or fat persons, and more so in muscular than in non- 
muscular. In short, I affirm that such a projection has occurred as 
often under my observation, when this dressing has been used, as it 
has when other forms have been employed. 

Finally, while I deprecate incautious assumptions in regard to the 
capabilities of any form of dressing for broken collar bones, a disposi- 
tion to which is manifested by more than one advocate of special 
plans, I am ready to bear my humble testimony in favor of that one 
of whose claims I have taken the liberty to speak so freely, and which 
is usually known in this country by the name of Fox's apparatus, 
consisting essentially of a sling, axillary pad, and bandages to secure 
the arm to the chest, and to which the stuffed collar is a convenient 
accessory, but admits of various modifications, answering the same 
ends. Among the considerable variety of dressings which I have 
used, this, either with or without such slight modifications as I shall 
presently suggest, has seemed to me most simple in its construction, 
the most comfortable to the patient, the least liable to derangement 



198 FRACTUKES OF THE CLAVICLE. 

(if I except Yelpeau's dextrine bandage), and as capable as any other 
of answering the several indications proposed. 

No apparatus is better able to answer the first indication, namely, 
" to carry the shoulder up," and thus to bring the fragments into line. 
If, as not unfrequently happens, the outer end of the inner fragment 
is also carried a little upwards and forwards, it may be, in some 
measure, replaced by inclining the head to the injured side, or by a 
carefully adjusted compress and bandage. But it is not probable that 
any patient will consent to remain a long time in a position so un- 
natural and constrained ; nor is it very easy, as the experiment will 
show, to maintain a steady pressure upon this portion of the broken 
clavicle. 

The second indication, " to carry the shoulder back," is certainly 
much more difficult of accomplishment than the first ; and it does not 
seem to me to be fully met by the sling dressing ; but until some mode 
is devised less objectionable than any I have yet employed, or than 
any, the mechanism of which I have seen described, I see no alterna- 
tive but to trust to that action of the muscles attached to the scapula, 
by w^hich, as Desault first explained, when the shoulder is lifted per- 
pendicularly, it is also in some degree carried backwards, and that, 
too, it has occurred to me frequently to observe, just as much as when 
the upward pressure is made with the elbow placed in front of the 
body. 

It is my belief, however, from the evidences now before us, that the 
third indication, " to carry the shoulder out," still remains unaccom- 
plished ; that it cannot be claimed for this, or for any other apparatus 
yet invented, that, in a certain class of cases which I have sufficiently 
indicated, constituting a vast majority of the whole number, it is able 
to prevent a riding of the fragments. Nor, seeing the difficulties in 
the way, and the amount of talent which has been already devoted to 
their removal, have I much confidence that this end, so desirable, and 
so diligently sough, will ever be attained. Yet it is presumptuous, 
perhaps, to say what the skill and ingenuity of a profession whose 
labors never cease, may not hereafter accomplish. 

Having already expressed my preference for the sling, I have only 
to add what I consider necessary modifications in the form of this 
dressing recommended by Dr. Fox. 

Dr. Coates, in the excellent paper already referred to, 1 calls attention 
to the danger of making too much pressure upon the brachial artery 
and nerves, when the axillary pad is used, and the arm is, at the same 
time, carried forwards upon the body. In bringing the elbow for- 
wards so as to lay the forearm across the body, the humerus is made 
to rotate inwards, and the brachial artery and nerves are brought into 
more direct apposition with the pad. The same objection must hold, 
only in a greater degree, to M. Gruillou's method of carrying the fore- 
arm across the back. 

The humerus ought then to be permitted to hang perpendicularly 
beside the body, and thus the nerves and bloodvessels will be removed 

1 Amer. Journ. Med. Sci., vol. xviii. p. 62. 



FKACTUKES OF THE CLAVICLE, 



199 



Fig. 48. 



in a great measure, yet not entirely, from pressure. The pad (to be 
employed only as a part of the retentive means, and not as a fulcrum) 
should be no thicker than is necessary to 
fill completely the axillary space when the 
elbow is made to press snugly against the 
side of the body. 

In consequence of having placed the 
elbow farther back than is recommended 
by Dr. Fox, it will be necessary, also, to 
vary, in some way, the suspensory tapes ; 
those coming from the humeral portion of 
the arm-tray must pass in equal numbers, 
and in opposite directions — before and be- 
hind the body — toward the stuffed collar ; 
and each set of front and back tapes, at- 
tached to the humeral portion of the tray, 
must be in pairs, for the convenience of 
tying. I find it necessary also to secure 
the arm to the body by two or three turns 
of a roller, applied always lightly and with 
great care, so that its pressure shall be in 
no degree painful or uncomfortable. 

In cases of partial fracture 1 accompa- 
nied with a persistent bend in the line of 

the axis of the bone, it is proper to make some attempt by moderate 
pressure directly upon the salient fragments, to restore them to place ; 
but I confess that I have never yet succeeded in accomplishing any- 
thing in this way. Nor is it a matter of much consequence, I imagine, 
since, as I have already explained, when speaking of partial fractures 
in general, the line of the axis of the bone will eventually, at least in 
a majority of cases, be completely restored. 

The only treatment which seems then to be indicated, and the only 
treatment which I have of late adopted in these cases, is to place the 
hand and forearm of the child in a sling, or I direct the mother to 
make fast the sleeve to the front of the dress in such a way that the 
child cannot use the arm until the union is consummated. Even this 
precaution I have several times omitted with no injury to the patient. 

For a more full consideration of partial fractures of the clavicle, I 
beg to refer the reader to the chapter on " Partial Fractures," &c. 




The Author's Apparatus. 



See Chapter on Incomplete Fractures. 



200 FRACTURES OF THE BODY OF THE SCAPULA. 



CHAPTEE XIX. 

FRACTURES OF THE SCAPULA. 

Fractures of the scapula may be divided into those which occur 
through the body, the neck, the acromion, and coracoid processes. 

§ 1. Fractures or the Body op the Scapula. 

Under this title I propose to consider not only fractures of the 
" body" properly speaking, but also fractures of the angles and of the 
spine. 

Causes. — It is usually broken by the fall of some heavy body directly 
upon the bone, or by some severe crushing accident, by the kick of a 
horse, by a fall upon the back — in short, by direct causes alone, and by 
such causes as operate with great violence. 

Malgaigne says that a Doctor Heylen has recently published a case 
of this fracture which he believes to have been the result of muscular 
action, occurring in a man forty-nine years old. The case, however, 
is not stated so clearly as to relieve us entirely of a doubt as to the 
nature and cause of the accident. 

I have myself had occasion to treat but two cases, one of which was 
produced by a fall upon the back, and the second, by the fall of a 
heavy weight upon the back. Dr. Neill called my attention to a 
fracture involving the spine of the scapula then under treatment in 
the Pennsylvania Hospital, in the year 1855. I have met with but one 
more example, except as the result of a gunshot wound. There are 
two cabinet specimens of fracture of the body of the scapula below the 
spine in the Pennsylvania Medical College, and two involving the 
spine. Dr. Mutter has in his collection a fracture of the posterior angle, 
and Dr. March has a specimen of fracture of the body. I believe 
also that in the collection of the late Dr. Charles Gibson, of Richmond, 
there are one or two specimens of this fracture. I know of no other 
museum specimens in this country except my own of partial fracture, 
described in the chapter on Partial Fractures. 

Ravaton, after a practice of fifty years, declared that he had never 
seen a fracture of the scapula, except as it had been produced by fire- 
arms. Among 2358 fractures reported from Hotel Dieu during a 
period of twelve years, only four examples of fracture of the scapula 
are recorded ; and at Middlesex Hospital, Lonsdale has noticed among 
1901 fractures, only eight of the body of the scapula. 

The infrequency of this fracture is no doubt clue in a great measure 
to the elasticity of the ribs, to the mobility of the scapula, and to the 
softness of the muscular cushion upon which it reposes. 



FKACTUKES OF THE BODY OF THE SCAPULA 



201 



Symptoms. — Since this bone is seldom broken except by great 
force directly applied, the usual signs of fracture are likely to be con- 
cealed by the speedy occur- 
rence of swelling. It is for Fig. 49. 
this reason that it becomes 
necessary, generally, that the 
examination should be made 
with great care before we 
can safely determine upon 
the diagnosis. I have more 
than once had occasion to 
correct the diagnosis of 
other practitioners, who be- 
lieved they had discovered 
a fracture of the scapula. 

When the line of the 
fracture has traversed the 
spine, and any considerable 
displacement has occurred, 
one ought to recognize the 
fracture easily by merely 
carrying the finger along 
the crest. In the example 
to which Dr. Neill called my 
attention in the Pennsylva- 
nia Hospital, although there 
was scarcely any displace- 
ment, the point of fracture 
could be distinctly felt ; and 
Dr. Husted, of New York, 
brought to my notice a similar case in Sept. 1860. It is only when 
the swelling over the seat of fracture is very great that any difficulty 
in the diagnosis need to exist, or perhaps in the case of a patient who 
is very fat. 

If the fracture has occurred through the body, below or above the 
spine, or through either of the angles, the displacement may not be so 
easily recognized. The surgeon ought then to trace carefully with his 
finger the outlines of the scapula, and this he will be able to do more 
satisfactorily if he places the scapula in such positions as elevate its 
margins and render them more prominent. In examining the poste- 
rior angle, the hand of the injured limb may be placed upon the oppo- 
site shoulder, the forearm being carried across the front of the chest ; 
but in searching for a fracture below the spine, the forearm ought to 
be laid across the back. 

Crepitus, which is not always present, owing to the fact that the 
fragments overlap completely, or because they have been widely sepa- 
rated by the action of the muscles, may generally be detected by 
placing the palm of the hand upon some portion of the scapula, so 
as to steady the fragment upon which it rests, while the arm is moved 
14 




Fracture of th 



MUtter' 



posterior angle of scapula, with fissure, 
collection, specimen C. No. 187. 



202 



FRACTURES OF THE SCAPULA 



backwards and forwards, and in various other directions, until their 
broken surfaces are brought into contact. 

Some degree of embarrassment in the motions of the shoulder and 
arm must always result from this fracture ; sometimes this embarrass- 
ment is very great, but it ought not to be considered ever as diagnostic 
of a fracture, since it may be produced equally by a severe contusion ; 
and even when it is accompanied with a fracture, it is due rather to 
the contusion than to the fracture. 

Pathology, seat, direction, &c. — Of incomplete fractures of the scapula, 
I have already mentioned that I have seen one example. 

Malgaigne thinks that he has seen one case of incomplete fracture, 
which occurred in a man who was injured by the fall of a heavy block 
of stone, upon his back ; but as the patient recovered, his diagnosis 
must remain doubtful. I know of no other recorded examples. 

Complete fractures occur most often below the spine, and they are 
generally oblique or transverse, sometimes nearly longitudinal. 

Fractures involving the spine are noticed occasionally, but I am 
not aware that any one has ever seen a specimen of a fracture of the 

spine alone, although many surgeons have 
spoken of them. 

I have mentioned one example of a frac- 
ture of the posterior angle as being in the 
cabinet of Dr. Mutter, of Philadelphia. 
Malgaigne seems to doubt its existence, 
but speaks of it as a fracture which sur- 
geons have ''imagined." 

Occasionally the bone is broken into 
more than two fragments. 

As a result of the fracture there is usually 
more or less displacement ; generally, if 
the fracture is below the spine and trans- 
verse, and especially if its direction is ob- 
lique from before backwards and down- 
wards, the inferior fragment is displaced 
forwards, or forwards and upwards, by the 
action of the serratus major anticus, or of 
the teres major, while the superior frag- 
ment is inclined to fall backwards, and sometimes it is carried upwards 
and backwards, following the action of the rhomboideus major. 

In cases of comminuted fracture, and occasionally in simple frac- 
tures, the direction of the displacement is reversed, or altogether 
changed, so that the lower fragment instead of being in front is behind 
the upper fragment, and instead of overlapping, the two fragments 
are more or less drawn asunder. These are deviations which are not 
easily explained, but which depend, perhaps, rather upon the direction 
of the blow than upon the action of the muscles. 

In a few cases there is no displacement in any direction, although 
the crepitus with mobility sufficiently demonstrates the existence of a 
fracture. 

Prognosis. — If displacement actually has taken place, it will be found 




Fractures of the body, and acromion 
process of the scapula. 



FEACTUBES OF THE BODY OF THE SCAPULA. 203 

very difficult, as we shall see when we come to consider the treatment, 
to hold the fragments in apposition, until a cure is completed : so that 
they are pretty certain to unite with a degree of overlapping, or other 
irregularity. 

Lonsdale, Lizars, Chelius, Nelaton, Gibson, Malgaigne, and others 
have spoken of the difficulty or impossibility generally of keeping 
these fragments in place. INFelaton and Malgaigne, indeed, confess that 
they have never succeeded; Gibson declares that it is scarcely possible; 
while Chelius affirms, that if the fracture is near the angle the cure is 
always effected with some deformity. 

But then it is not probable that the patient will ever suffer any 
serious inconvenience from this irregular union of the fragments, since 
the perfection of its function depends less upon any given form or size 
than in the case of almost any other large bone ; and if, as has been 
observed by Lonsdale, the free use of the arm is not recovered for some 
time, or if, as has been noticed by B. Bell, a permanent stiffness results, 
these should be regarded as due to the injury which those muscles 
have suffered which envelop the scapula, or to some injury of the 
ligaments and muscles which surround the shoulder joint. In Dr. 
Husted's case, already noticed by me, there existed, thirty-five days 
after the accident, when he was presented to me, both partial paralysis 
of the arm and considerable anchylosis at the shoulder-joint. 

In some few examples upon record, the bone has been so commi- 
nuted, and the soft parts adjacent so much injured that suppuration 
and necrosis have ensued. And in a recent case of gunshot fracture 
of the scapula, attended with much comminution, and resulting in 
necrosis, I have had occasion to remove the entire scapula. 

Treatment.— In the treatment of this fracture, the first object with all 
surgeons has been to restore the fragments to place, and this they have 
chiefly sought to accomplish by position ; after which, they have en- 
deavored to immobilize the fragments by bandages, &c. 

In seeking to accomplish the first indication, they have placed the 
shoulder and arm in a great variety of postures. Nearly all seem to 
have regarded it as of some importance that the shoulder should be 
elevated, so as to relax the muscles attached to the upper and back 
part of the scapula, and thus permit the upper fragment to fall down- 
wards and forwards. 

If we confine our remarks first to fractures through the body, and 
do not include fractures of the inferior angle, this indication is the 
only one which Nelaton and Mayor have sought to accomplish, and 
for this purpose they employ a simple sling, while Amesbury, Liston, 
Lonsdale, S. Cooper, South, Skey, Miller, Pirrie, have added to the 
sling a bandage or roller, which is made to inclose snugly the body 
and arm. 

Erichsen uses the body bandage alone, as in fractures of the ribs, 
while B. Cooper, Lizars, and Tavernier employ a bandage which in- 
closes not only the body, but also the arm ; neither of these last-men- 
tioned surgeons recommends a sling, or any other means to elevate 
the arm. 

Johannes de Gorter advises that a sling shall be used, but that the 



204 FEACTUKES OF THE SCAPULA. 

elbow shall be lifted away from the side of the body, so as to relax 
the deltoid. Chelius and Desault recommend the same position, but 
with the addition of an axillary pad, whose apex shall be directed 
upwards, secured in place with appropriate bandages. 

Pierre d'Argelata used also an axillary pad, but instead of a wedge 
he recommended a simple roll; and instead of lifting the elbow away 
from the body, he directed that the elbow should be secured against 
the side, making use of the axillary roll as a fulcrum. 

Petit and Heister advised that the elbow and forearm should be 
carried forwards upon the front of the chest, and secured in this 
position. 

In the treatment of no other fracture perhaps have surgeons differed 
more widely as to the indications than in this, since, as we have seen, 
some recommend the elbow to be carried from the body, and some that 
it shall be made to approach the body; one directs that the elbow 
shall fall perpendicularly beside the chest, a second prefers that it shall 
be carried a little back, and a third that it shall be brought well for- 
wards. In one thing alone have they nearly all agreed, namely, that 
the elbow shall be lifted ; and generally also it has been recommended 
that the arm, forearm, and body shall be confined by sufficient band- 
ages to insure quietude. It might be proper to conclude, therefore, 
that the sling and bandage constitute all of the apparatus which is 
necessary or useful ; and that it is relatively unimportant whether the 
elbow is near or remote from the body, or whether it is in front of, or 
behind, or beside the chest. 

Such, indeed, is the conclusion to which we have ourselves arrived; 
yet if, in relation to the position of the elbow, a choice were to be 
expressed, we would give the preference to that in which the arm is 
laid vertically beside the body, or, perhaps, with the elbow a little 
inclined backwards, so as to relax as completely as possible the teres 
major. 

It is quite probable, however, that no single position will be found 
of universal application ; and perhaps it would be more safe to advise 
the surgeon in any given case first to reduce the fragments as com- 
pletely as possible by manipulation, and then to place the arm in such 
a position as, upon careful experiment in this particular instance, he 
shall find enables him to best retain them in place. 

If, however, the fracture is such as to have separated the inferior 
angle from the body, it will be well to follow the advice of Boyer and 
of others, and to place a compress in front of the inferior angle to 
resist the greater tendency to displacement in this direction. This 
compress will more effectually accomplish this indication if the roller 
with which it is secured to the body, and with which we seek to im- 
mobilize the scapula and chest, is turned from before backwards, or 
in a direction of antagonism to the action of the muscles which pro- 
duce the displacement. 

Desault, with Chelius and Bransby Cooper, has recommended also, 
in the case of a fracture through the angle, that the forearm should 
be acutely flexed upon the arm, and that the hand should be placed in 
front of the chest, upon the sound shoulder, a position which is always 



FRACTURES OF THE Is T ECK OF THE SCAPULA. 



205 



irksome, and sometimes insupportable, and which does not offer in any 
case sufficient advantages to render it worthy of a trial. 



§ 2. Fractures of the Neck of the Scapula. 

If by the " neck" of the scapula, surgeons mean that slightly con- 
stricted portion of this bone which is situated at the base of the glenoid 
cavity, and it is to this portion, we believe, that anatomists have 
generally applied the term " neck," then its fracture is certainly very 
rare. Indeed, the existence of this fracture, uncomplicated with a 
comminuted fracture of the glenoid cavity, is denied by Sir Astley 
Cooper, South, Erichsen, and others. Mr. South says there is no such 
specimen in any of the museums in London ; and I have not been able 
to find one in any of the American cabinets. Dr. Mott has said to me 
that he had never seen a specimen, and that in the natural condition 
of the bone he regards its occurrence as impossible. Such, I confess, 
also, is my own conviction. 

If, however, it is intended, in speaking of fractures of the neck of 
the scapula, to refer, as Sir Astley Cooper has done, only to fractures 
extending through the semilunar notch, behind the root of the cora- 
coid process, then its existence is certain; yet the fracture is not com- 
mon. Duverney has reported one example, the existence of which he 
established by a dissection. The coracoid process was broken at the 
same time, but the fracture through what was called the neck, was 
distinct from this: and Sir Astley has recorded three examples in 



Fig. 51. 



Fig. 52. 





Comminuted fracture of the glenoid 
cavity. 



Fracture of the neck of the scapula ; according to 
Sir Astley Cooper. 



which the diagnosis was very clearly made out, yet not actually proven 
by an autopsy. 

Symptoms.— -Sir Astley justly remarks that "the degree of deformity 



206 FKACTUKES OF THE SCAPULA. 

produced by this accident depends upon the extent of laceration of a 
ligament which passes from the under part of the spine of the scapula 
to the glenoid cavity. If this be torn" (and to this we ought to add 
the ligaments passing from the coracoid process to the clavicle and 
acromion process) "the glenoid cavity and the head of the os humeri 
fall deeply into the axilla, but the displacement is much less if this 
remains whole." 

The usual signs are, a depression under the acromion process, the 
same as in dislocation of the head of the humerus downwards, but not 
so deep ; the head of the humerus felt, perhaps, in the axilla ; crepitus, 
and the immediate recurrence of the displacement whenever, after the 
reduction has been fairly accomplished, the arm is left unsupported. 
The crepitus is best discovered by resting one hand upon the top of 
the shoulder in such a manner as that a finger shall touch the point 
of the process, while the arm is rotated and moved up and down by 
the opposite hand. It may also be easily ascertained that the cora- 
coid process moves with the humerus instead of the scapula. Occa- 
sionally, the accident is accompanied with paralysis of the arm, from 
pressure upon the axillary nerves, and a rupture of the axillary artery 
is also mentioned by Dugas. 1 

Treatment. — The indications of treatment are three, namely, to-carry 
the head of the humerus, with the glenoid cavity, &c, up, to carry it 
out, and to confine the body of the scapula. The first is accomplished 
by a sling, the second, by a pad in the axilla, and the third by a broad 
roller carried repeatedly around the arm and chest and across the 
shoulder. 

§ 3. Fractures of the Acromion Process. 

Examples of fracture of the acromion process have been reported 
by Duverney, Bichat, Avrard, A. Cooper, Desault, Sanson, Nelaton, 
Malgaigne, West, 2 Brainard, 3 Stephen Smith 4 and others. I have 
myself seen three examples. 5 

In the case seen by Cooper it entered the articulation of the clavicle, 
and produced at the same moment a dislocation. Malgaigne says it 
occurs generally farther up, and posterior to the attachments of the 
clavicle, "near the junction of the diaphysis with the epiphysis," and 
that the fracture is in most cases transverse and vertical ; but Nelaton 
saw a case in which the fracture was oblique. In the case reported 
by C. West, of Hagerstown, Md., the fracture was through the base 
of the process. In two of the examples seen by me the fracture was 
in front of the clavicle; and in the third, occasioned by the fall of a 
barrel of flour upon the shoulder, the fracture occurred at the acro- 
mio-clavicular articulation, and was accompanied with an upward 
dislocation of the outer end of the clavicle. 

1 Remarks on Frac. of Scapula, by L. A. Dugas, Georgia. Am. Journ. Med. Sci., 
Jan. 1858. 

2 West, Penin. Journ. of Med., vol. v. p. 254. 

s Brainard, Bost. Med. and Surg. Journ., vol. xxxi. p. 501. 
4 5 S. Smith. Hamilton, Report on Deform., op. cit. 



FKACTUKES OF THE ACROMION PROCESS. 207 

There is some reason to believe, I think, that a true fracture of the 
acromion process is much more rare than surgeons have supposed, 
and that in a considerable number of the cases reported there was 
merely a separation of the epiphysis ; the bony union having never 
been completed. If such fractures or separations occurred only in 
children, very little doubt might remain as to the general character of 
the accident; but the specimens which. I have found in the museums, 
and the cases reported in the books, have been mostly from adults. 
It is more difficult, therefore, to suppose these to be examples of sepa- 
ration of epiphysis, but I am inclined to think that in a majority of 
instances such has been the fact. It is very probable, also, that in 
the case of many of the specimens found in the museums, called frac- 
tures, the histories of which are unknown, they were united originally 
by cartilage, and that in the process of boiling, or of maceration, the 
disjunction has been completed. The narrow crest of elevated bone 
which frequently surrounds the process at the point of separation, and 
which Malgaigne may have mistaken for callus, is found upon very 
many examples of undoubted epiphyseal separations which I have 
examined ; and this circumstance, no doubt, has tended to strengthen 
the suspicion that these were cases of fracture. 

This opinion is confirmed by the remark of Mr. Fergusson, that a 
fracture of this process is an accident " of rare occurrence." " I have 
dissected," he adds, " a number of examples of apparent fracture of the 
end of this process ; but in such instances it is doubtful if the movable 
portion had ever been fixed to the rest of the bone." Dr. Jackson 
says there are four specimens in the museum of the Massachusetts 
Medical College, and in the museum of the Boston Society for Medi- 
cal Improvement, which might easily be mistaken for fractures, but 
which only illustrate to how late a period the bony union is sometimes 
delayed. In one specimen the patient could not have been less than 
forty years of age ; " the acromial process of each scapula was fully 
formed, but having no bony union whatever with the bone itself. The 
union was ligamentous, but strong and close." 

To the same class belong several specimens in my own collection ; 
specimens 163 and 997 in Dr. March's collection ; 707 in the Albany 
College Collection ; two specimens in the Mutter, and one in the Jef- 
ferson Medical College museums. 

I wish to mention, also, that in the case of my own specimens of 
epiphyseal separation, as well as most of the specimens which I have 
examined, the ends of the fragments were closed with a compact bony 
tissue. 

The mode of development of the scapula will explain these cases. 
The scapula is formed from seven centres ; namely, one for the body, 
one for its posterior border, one for its inferior border, two for the 
acromion process, and two for the coracoid. Ossification of the body 
exists to a certain extent at or near the period of birth. It commences 
in one of the centres of the coracoid process, about one year after 
birth, and unites to the body at about the fifteenth year. All the 
other centres remain cartilaginous until from the fifteenth to the 
seventeenth years, when ossification commences, and is completed by 



208 



FRACTURES OF THE SCAPULA. 



a common union among all parts, usually between the twenty-second 
and twenty-fifth years. 

Fig. 53. 




Scapula, with epiphyses. (From Gray.) 

No doubt, however, a fracture of this process does occasionally take 
place. In addition to my own, I have already mentioned several 
other examples, some of which have been confirmed by dissection ; 
and in the case mentioned by Stephen Smith, an autopsy, made three 
weeks after the accident, showed a fracture without displacement, the 
periosteum covering its upper surface not being torn; the fragment 
could be turned back as upon a hinge. 

Prognosis. — The process generally unites with a slight downward 
displacement. This occurred in at least two of the examples seen by 
me ; but in such cases the motions of the arm are not in consequence 
much, if at all, embarrassed ; unless, indeed, it is so much depressed 
as to interfere with the upward movements of the arm ; a result which 
Heister erroneously supposed was inevitable. 

Sir Astley Cooper says that a true bony union is rare in these frac- 
tures, and that there generally results a false joint, the fragments 
uniting by a fibrous tissue ; but sometimes the surfaces, instead of 
uniting either by bone or ligament, become polished, and even ebur- 
nated. 



FRACTURES OF THE CORACOID PROCESS. 209 

Malgaigne lias noticed, also, in a specimen contained in the Dupuy- 
tren museum, a hypertrophy of the lower fragment, this portion having 
a diameter nearly twice as great as that of the portion from which it 
was detached. 

Symptoms. — Where no displacement exists, the diagnosis must 
always be difficult, if not impossible. In such a case we could only 
be instructed by the manner in which the injury had been received, 
by the contusion, and by the presence of mobility or crepitus. 

In examples attended with displacement, if no swelling is present, 
the finger carried along the spine of the scapula to its extremity, will 
easily detect the fracture by the abrupt termination of the process, or 
by the presence of a fissure, or a depression; but as to the other symp- 
toms, they must depend very much upon the point at which the 
fracture has taken place. If in front of the acromio-clavicular articu- 
lation, the position of the arm in its relations to the body will not be 
changed ; but if the fracture is through the articulation, and a dis- 
location of the clavicle results, or if it is behind the acromio-clavicular 
articulation, the arm, having in either case lost the support of the 
clavicle, will assume the same position that it does in a fracture of 
the clavicle ; that is, the shoulder will fall downwards, inwards, and 
forwards. 

Treatment. — If the fracture has taken place in front of the acromio- 
clavicular articulation, no doubt the most rational plan of treatment 
is that recommended by Delpech; that is, placing the patient in bed, 
upon his back, and carrying the arm out from the body nearly to a 
right angle ; since by this method the fragment is not only lifted, but 
the deltoid muscle is relaxed, and, consequently, the fragment is no 
longer forcibly drawn away from the spine of the scapula. If, there- 
fore, the patient will submit to this treatment for a sufficient length of 
time, the union must be accomplished with the least possible amount 
of displacement. In case he will not consent to such confinement, I 
am confident no other plan which has been recommended merits a 
trial, unless it be simply to place the arm in a sling until the union is 
accomplished. 

If, however, the fracture has taken place at, or behind the junction 
of the clavicle with the process, the indications of treatment must be 
in all respects the same as in a fracture of the clavicle. 



§ 4. Fractures op the Coracoid Process. 

I am surprised that Mr. Lizars should have never seen a case or 
heard of a well authenticated example of a fracture of the coracoid 
process. "The coracoid process," he remarks, "is said to be broken 
off, but this I question very much ; it must be along with the glenoid 
cavity, or there must be a fracture of the neck of the scapula." 

Dr. Neill, of Philadelphia, has in his cabinet a specimen of separa- 
tion of this process at about one inch from its extremity. The line of 
separation is somewhat irregular ; there is no callus, but it is united 
to the upper portion by a dried tissue, half an inch in length, and con- 



210 FRACTURES OF THE SCAPULA. 

tinuous with the periosteum. This has been regarded as an example 
of fracture; but although the scapula is large and evidently belongs to 
an adult, the fact that the acromion process is not yet united by bone, 
renders it probable that this, also, is an epiphyseal separation. Prof. 
Charles Gibson, of Eichmond, Va., informs me also that he has in his 
cabinet a dried specimen, from an adult, which has been broken ob- 
liquely near the end, but which is now united by a ligamentous or 
fibrous tissue of one line and a half in length. The fragment is dis- 
placed a little forwards, as well as downwards. Eeuben D. Mussey, 
of Cincinnati, is in possession of a very remarkable and conclusive ex- 
ample of this fracture. The humerus is dislocated forwards, the head 
and neck being firmly united to the neck and venter of the scapula, 
while at the same time the coracoid process is broken and displaced. 
Dr. Jackson, of Boston, says that specimen No. 453 in the museum of 
the Massachusetts Medical College, seems clearly to have been a frac- 
ture involving the base of the coracoid process, and which, having 
taken place somewhere within a year of the death of the person, had 
become united by bone, and that just before death the process had 
broken off, and so completely, as to involve a portion of the glenoid 
cavity. 1 

Bransby Cooper relates a case of fracture through the base, which 
after eight weeks, when the patient died, was found to be united by a 
ligament. The acromion process was broken at the same time, and 
had united in the same manner. The head of the humerus was also 
broken and partly united, 2 One example is said to have occurred in 
the practice of Dr. Arnott, at the Middlesex Hospital, London, in 
consequence of which the patient died, when a dissection disclosed 
the true nature of the accident. 3 Mr. South has also reported a case 
resembling somewhat Mussey's, but much more complicated. The 
humerus was partially dislocated forwards, the clavicle, acromion pro- 
cess, and the olecranon were broken as well as the coracoid process. 
Neither the fracture of the clavicle nor of the coracoid process was 
made out until after the patient died, which was on the fourth day ; 
the fact of the existence of these fractures being then ascertained by 
dissection. 4 Erichsen says there is in the museum of the University 
College, a preparation showing a fracture at the base of this process, 
the line of fracture extending across the glenoid cavity. 5 Duverney, 
Boyer, and Malgaigne have also reported four additional examples 
confirmed by dissections. 6 

The existence of this form of fracture, established by at least nine 
or ten dissections, can no longer be denied ; yet it is usually accom- 
panied with serious complications, such as must in most cases prove 
fatal. In the only case, however, in which I have had reason to 
believe that I had to deal with a fracture of this kind, the symptoms 
and termination were less grave, although it was complicated with an 

1 The author's Report on Deformities, op. cit. 

2 B. Cooper, edition of Sir Astley on Frac. and Disloc, Amer. ed., p. 380. 

3 Arnott, Fergusson's Surg., p. 213. 

4 South, Lond. Med.-Chir. Rev., 1840, vol. xxxii., new series, p. 41. 

6 Erichsen, Surgery, p. 207. 6 Malgaigne, op. cit., p. 512. 



FEACTUEES OF THE COEACOID PEOCESS, 



211 



Fig. 54. 



upward dislocation of the outer end of the clavicle. A gentleman 
residing in the country was struck by a board which fell edgewise 
upon his shoulder. The fracture of the coracoid process does not 
seem to have been recognized by his surgeon. An apparatus was ap- 
plied to retain the clavicle in its place, but after three months, when 
he called upon me, it still remained displaced as at first. During all 
of this time the apparatus had been steadily kept on. On laying off 
the dressings I discovered that the coracoid process was detached, 
obeying constantly the movements 
of the head of the humerus, but being 
not at all subject to the movements 
of the scapula. Some months later 
I examined the arm again, and found 
the parts in the same condition as be- 
fore, but the functions of the arm 
were not impaired. 

It has been generally stated that 
when this process is broken off, it 
will be carried downwards by the 
united action of the pectoralis minor, 
the short head of the biceps, and the 
coraco-brachialis muscles ; but this 
will depend upon whether the coraco- 
clavicular ligaments are ruptured 
also ; a circumstance which is not 
very likely to occur, at least to any great extent ; and in fact not one 
of the well-attested examples of this fracture has ever been accom- 
panied with any considerable displacement in this direction. 

Treatment. — In a case of simple fracture of the process unattended 
with any other lesions, it is sufficient to place the arm in a sling with 
the elbow advanced as much as possible upon the front of the chest ; 
as by this position we relax somewhat all of the three muscles having 
attachments to this process. If we were to add anything to this simple 
procedure it would be merely to confine the scapula by a few turns 
of a roller. It is not probable, however, that by either, or both of 
these measures we should accomplish enough to justify their continu- 
ance if they were found to be painful, or even exceedingly irksome. 

In the graver forms of the accident, where other bones about the 
shoulder are broken or dislocated, which, as we have seen, constitute 
the larger proportion of the whole number, the treatment must gene- 
rally have little or no regard to this particular injury. 




Fracture of the coracoid process. 



212 



CHAP TEE XX. 

FRACTURES OF THE H U M E R U S . 

It is not sufficient to consider fractures of this bone as occurring 
through the shaft and its two extremities, as some systematic writers 
have done; since upon this simple arrangement it is impossible to base 
a natural division of their causes, symptoms, prognosis, and treatment. 

We shall find it necessary to consider, 

I. Fractures of the head and anatomical neck. (Intra-capsular ; non- 
impacted and impacted.) 

2 Fractures through the tubercles. (Extra-capsular : non-impacted 
and impacted.) 

3. Longitudinal fractures of the head and Deck, or splitting off of 
the greater tubercle. 

- Fractures of the surgical neck. (Including separations at the 
upper epiphysis.) 

5. Fractures through the body of the shafts or, of the shaft below 
the surgical neck and above the base of the condyles. 

6. Fractures at the base of the condyles. (Including separation at 
the lower epiphysis. 

7. Fractures :-.: the base, complicated with fractures between the 
condyles, extending into the joint. 

8. Fractures or separations of the internal epicondyle. 

9 . Fractures or separations of the external epicondv le. 

10. Fractures of the internal condyle. 

II. Fractures of the external condyle. 

Of 113 fractures of the humerus examined by me, 25 occurred 
through the upper third, 17 through the middle third, and 71 through 
the lower third. An observation which is in contrast with the state- 
ment made by Amesbury, and which has been repeated by Liza re Z 
Cooper, Fergusson, Gibson, and others, that this bone is most often 
broken in its middle third. 

Of the fractures belonging to the upper third, one was a separation 
at the junction of the epiphysis with the shaft, one was robably a 
:: :::re at or near the anatomical neck, with impaction and splitting 
of the tubercles, one was a fracture of the greater tubercle alone, and 
16 were fractures of the surgical neck. 

Of the fractures belonging to the lower third, 15 were through the 
internal condyle and epicondyle, 18 through the external condyle, 16 
were at the base of the condyles, 6 through the condyles and ti- 
the base at the same time. The remainder, 16, being through the 
shaft, but above the base. 

V::::::t;.:r-7. sar^ital writers "a are at: teen arreei ia :ae a = e :a.. 
application of the terms u head," " neck/' " anatomical neck," and " sur- 



FRACTURES OF HEAD AND ANATOMICAL NECK. 213 

gical neck" of the humerus ; and., as a consequence, their meaning is 
often obscure, and their teachings are sometimes contradictory and 
absurd. 1 It is necessary, therefore, that we should define them more 
precisely. 

The head of the humerus is that smooth, elliptical surface, covered 
by cartilage and synovial membrane, which articulates with, and is 
received into the glenoid cavity of the scapula. 

The anatomical neck is the narrow line immediately encircling the 
head, and which receives the insertion of the capsular ligament. 

The surgical neck is that portion which commences at the lower 
margin of the tubercles, or at the point of junction between the epi- 
physis and the diaphysis, and which terminates at the insertion of the 
pectoralis major and latissimus dorsi. 

The neck is all of that portion included between the head and the 
insertion of the pectoralis major and latissimus dorsi, comprising not 
only the anatomical and surgical necks, but also the tubercles, which 
occupy the triangular space between these two. 



§ 1. Fbactures of the Head and Anatomical Neck. (Intra- Capsular ; 
Non-impacted, and Impacted.) 

Causes. — The causes which have been found competent to produce 
fractures of the head and anatomical neck are, the penetration of balls 
or of other missiles directly into the joint, producing thus a compound, 
and generally comminuted fracture of the head ; or falls or direct 
blows upon the shoulder without penetration. 

Pathology, Results, &c. — When the fracture results from the direct 
penetration of some foreign body into the joint, it is not only a com- 
pound fracture, but the head of the bone is almost necessarily broken 
into fragments. If the patients recover, sooner or later the frag- 
ments have generally to be removed. 

Fractures of the anatomical neck, produced by falls upon the 
shoulder without penetration, are, however, usually neither compound 
nor comminuted, but they often follow, with a remarkable degree of 
accuracy, the line of the insertion of the capsular ligament, being 
always according to Eobert Smith, within the inferior or outer mar- 
gin of this insertion. He calls them, therefore, intra-capsular. It is 
probable, however — since, as we shall presently see, bony union is not 
denied to this fracture — that the line of separation is not always, or 
generally, perhaps, completely within the insertion of the ligament, 
but that it is in some degree extra-articular, if not extra-capsular. If 
it is entirely intra-articular, no doubt union of the fragments can never 
take place, and generally suppuration will ensue, demanding, at a 
period not very remote, an operation for their removal, the same as 
in compound fractures. 

Gibson, however, thinks that the fragment occasionally remains, 
being gradually absorbed and changed in figure. He says that his 

1 Boston Med. and Surg. Journ., June 24, 1858, p. 410. 



214 



FEACTUEES OF THE HUMEEUS. 



Fig. 55. 




Fracture of the anato 
mical neck. 



museum contains three or four well-marked cases of this kind, in all 
of which the head has lost its spherical form, and 
is very much diminished, and rough and flattened 
next to the scapula. 1 Other cabinets contain similar 
specimens. 

The displacements to which the upper fragment, 
or the head of the bone, is subject, are remarkable, 
and some of them do not seem to be satisfactorily 
explained. Frequently, indeed, its position is not 
sensibly disturbed, but at other times it is found 
impacted, or driven into the cancellous structure 
of the inferior fragment, in consequence of which 
one or both of the tubercles are frequently broken 
off. 

Eobert Smith relates the following: case as having 
afforded him his first opportunity of ascertaining 
by post-mortem examination, the exact nature of 
this form of displacement : — 

"A female, set. 47, was admitted into the Eich- 
mond Hospital under the care of the late Df. Mc- 
Dowell, for an injury to the humerus, the result 
of a fall upon the shoulder. Five years afterwards, the woman was 
again admitted, under the care of Mr. Adams, with an extra-capsular 
fracture of the neck of the femur, one month after the occurrence of 
which, she died, in consequence of an attack of diarrhoea. 

"The shoulder was of course carefully examined; the arm was 
slightly shortened, the contour of the shoulder was not as full or 
round as that of its fellow, and the acromion process was more promi- 
nent than natural. Upon opening the capsular ligament, the head of 
the humerus was found to have been driven into the cancellated tissue 
of the shaft, between the tuberosities, so deeply as to be below the 
level of the summit of the greater tubercle ; this process had been 
split off, and displaced outward ; it formed an obtuse angle with the 
outer surface of the shaft of the bone." 2 

The description is accompanied with two excellent drawings of the 
specimen, showing the distance to which the superior fragment had 
penetrated the inferior, and showing also complete union by bone. 

I believe, also, that in the following example there was a fracture 
at or near the anatomical neck, with impaction, and splitting of the 
tubercles : — 

January 12, 1858, a young man, aged about sixteen years, fell from 
a height in a gymnasium, severely injuring his left shoulder. I saw 
him, with Dr. Boardman, soon after the accident, and found him com- 
plaining very much of the shoulder, which was some swollen and 
tender. He could not tell us how he fell, nor could we discover any 
contusions by which to determine the point where the blow was re- 
ceived. All motions of the shoulder-joint were painful ; and there 



1 Gibson, Elements of Surgery, vol. i. p. 279. 

2 South, Fractures in Vicinity of Joints, pp. 191-3. 



FRACTURES OF HEAD AND ANATOMICAL NECK. 215 

was a remarkable fulness in front of the joint, feeling like the head of 
the bone, yet not such as is usually present in a forward luxation. To 
determine this more positively, however, the limb was manipulated as 
for the reduction of a dislocation. Once during the manipulation a 
feeble but distinct crepitus was detected ; yet the position of the bone 
remained unchanged. The head was found to be in the socket, but 
the precise nature of the injury was not made out. 

Fifteen days later, when the swelling had completely subsided, a 
careful examination was again made by Dr. Boardman and myself, 
when we arrived at the conclusion that it was a fracture through the 
bicipital groove, and that the lesser tubercle was carried forward half 
an inch or more from its fellow, while the head and the greater tu- 
bercle occupied their natural positions opposite the socket. The 
fragment projecting in front presented a sharp point, and could not be 
confounded with any swelling of the soft parts. There was a distinct 
space between the tubercles, into which the finger could be laid. .No 
depression existed under the acromion process behind, but on mea- 
surement the head of this humerus was found to be half an inch wider 
in its antero-posterior diameter than the opposite. 

That this fracture was accompanied with impaction was rendered 
certain by the repeated and careful measurements of the length of the 
humerus, which constantly showed a shortening of half an inch. 

Under these circumstances union generally takes place ; but it is 
usually accompanied with the formation of an irregular mass of osteo- 
phytes, which encircle the head like a coronet; presenting in this 
respect again a remarkable resemblance to extra-capsular fractures of 
the neck of the femur. This ensheathing callus, as it may be called, 
is an outgrowth from the inferior fragment, and it sometimes incloses 
the upper fragment as the case of a watch incloses the crystal, only in 
a manner much more irregular, thus retaining it steadily in its place, 
although very little direct union has occurred. The cancellous tissue, 
nevertheless, is occasionally found united completely by a new and 
intermediate bony tissue, and at other times by a fibrous tissue, or by 
both fibrous and bony tissue. 

In some cases a perfect false joint has been formed between the 
opposing surfaces, while in a few unfortunate examples the head not 
only refuses to unite, but by its presence, as we have already remarked, 
produces inflammation and suppuration, resulting in its final extrusion 
from the joint. 

At other times the upper fragment turns upon its own axis, and is 
found more or less tilted or completely rotated in the socket ; so that 
its cartilaginous or articulating surface rests upon the broken surface 
of the lower fragment and its own broken surface presents toward 
the glenoid cavity. 

Kobert Smith has described a specimen of this kind which he re- 
moved from the body of a woman, aged forty, who many years pre- 
vious to her death fell down a flight of stairs, and struck her shoulder 
with great violence against the edge of one of the steps. Whether 
she applied to a surgeon or not at the time of the accident, Mr. Smith 



216 



FRACTURES OF THE HUMERUS. 



Fig. 56. 



Fig. 57. 



m 



was not able to ascertain. After death the shoulder looked somewhat 
as if there was a dislocation of the humerus into the axilla, there being 
a marked depression under the acromion process, but the shaft of the 
humerus was drawn upwards and inwards toward the coracoid pro- 
cess. 

When the capsular ligament was opened, the head of the bone was 
found to have been broken from the shaft through the line of the ana- 
tomical neck, and to have completely turned upon itself; and the 
cartilaginous surface was actually driven one inch into the cancellated 
structure of the shaft, so as to split off the lesser tubercle with a por- 
tion of the greater. Only one-half of the upper fragment was thus 
impacted, the other half projecting beyond the margin of the lower 
fragment. Between the cartilaginous surface and the shaft no union 
had occurred; but there was complete bony union between the upper 
and lower fragment, beyond the limits of the cartilage. 

The upper surface of the superior fragment rested in part against 
the inner half of the glenoid cavity and upon its inner margin, and in 

part it rested against the neck of the 
scapula in the direction of the cora- 
coid process. 1 

Nelaton saw a similar specimen in 
the possession of M. Dubled, the re- 
volution of the upper fragment being 
complete ; but there was no later dis- 
placement, and the union had been 
accomplished in a manner similar to 
that which is seen after intra-capsu- 
lar, impacted fractures, without re- 
version. 2 

I have also been permitted to ex- 
amine a specimen belonging to Dr. 
Charles A. Pope, of St. Louis, Mo., 
which seems to have been broken 
not only through the line of the 
anatomical neck, but also through 
the surgical neck. Both fragments 
are united by bone, the lower frag- 
ment being carried in the direction of 
the coracoid process, while the upper 
fragment appears to be reversed, so 
that its articular surface is directed 
toward the shaft, and its broken 
surface articulates with the glenoid 
cavity. The history of this specimen 
is unknown. 

It is possible, we think, that these 
extraordinary changes of position 



: /; 



t 



Dr. Pope's Specim- 
Front view. 



Side view. 



1 R. Smith, op. cit., pp. 193-6. 

2 Nelaton, Elements de Pathol. Chirur., torn. prem. p. 307 



FRACTURES OF HEAD AND ANATOMICAL NECK. 217 

were not the direct result of the accident which broke the bone, but 
that they had been taking place gradually and through a long period. 
It is certainly quite as probable that the constant motions of the 
arm should accomplish these displacements, as that they should be 
produced by a direct blow; indeed, the former supposition appears 
to us much the most probable. 

There is another supposition which, in my opinion, is capable of 
explaining most of the phenomena usually present in these cases, 
and which, if admitted, renders the supposition of a fracture unne- 
cessary. It is, that these are all of them examples of softening of 
the neck of the bone, as a result of chronic inflammation, ulceration, 
&c. ; and that the changed position of the head is due to pressure 
alone, being acted upon by the muscles which surround the joint, 
and which act all the more vigorously because they partake also of 
the inflammation which has invaded the bone. This view of these 
specimens, which had already more than once suggested itself to me, 
was very strongly confirmed by its having occupied the mind also of 
Dr. Neill, of Philadelphia, and who at his own instance stated to me 
that he believed this was their true explanation. We were, at the 
time, examining Dr. Pope's specimen, already alluded to, and on com- 
paring it with a specimen of dislocation and partial absorption of the 
head of the humerus, contained in Dr. Keill's Museum, the points of 
resemblance were so numerous and striking that we felt compelled to 
doubt whether Dr. Pope's specimen, together with those seen by Smith 
and Nelaton, did not belong to the same class with this of Neill's. 

In a case of fracture of the "cervix humeri within the capsular liga- 
ment," examined by Sir Astley Cooper, there was also a complete 
forward luxation of the head ; but ligamentous union had occurred 
between the fragments. 1 Many similar cases have been reported by 
other surgeons. 



§ 2. Fractures through the Tubercles. (Extra-capsular ; Non-impacted 

and Impacted.) 

Under this division we intend to speak of all fractures traversing 
the upper end of the humerus, and involving the tubercles, or of all 
those which occur between the anatomical neck on the one hand, and 
the epiphyseal junction, or surgical neck, on the other hand, and which 
may be more or less oblique as well as transverse. Fractures of the 
greater or lesser tubercles are of course excepted, since they are more 
properly longitudinal fractures, and do not completely traverse the 
diameter of the bone. Nor do we intend to include those fractures 
which occur at the epiphyseal junction, since, being below the princi- 
pal insertion of those muscles which are attached to the tubercles, they 
present very peculiar and distinctive features which will demand for 
them a separate classification. 

Causes, Pathology, and Results. — Fractures through the tubercles, 

1 A. Cooper on Dislocations, &c, p. 372. 

15 



218 FRACTURES OF THE HUMERUS. 

like fractures through the anatomical neck, are the results generally 
of direct blows received upon the shoulder. They are not usually 
accompanied with much lateral displacement at the point of fracture ; 
a circumstance which finds a partial explanation in the fact that the 
line of fracture is through the insertions of the muscles converging 
upon the tubercles and not entirely above or below them, so that they 
continue to act nearly equally upon both fragments ; but it is also 
sometimes due in a measure to impaction : the head being forced 
downwards toward the axilla, and upon the shaft until it is made to 
ride upon its inner or axillary wall like a cap ; the compact bony 
tissue of the shaft penetrating the reticular structure of the head. 
These fractures generally unite by bone ; yet more or less impairment 
of the motions of the limb results from the inflammation which occurs 
in and about the joint, or from the irregular deposits of callus in the 
vicinity of the fracture. 



§ 3. Longitudinal Fractures op the Head and Neok ; or Splitting off 
of the Greater Tubercle. 

Causes, Pathology, Symptoms, and Results. — Mr. Guthrie seems to 
have been the first to call attention to this peculiar injury of the 
shoulder. In a lecture delivered in November, 1833, he described 
four cases which had come under his observation, and which he re- 
garded as examples of separation of the small tuberosity, accompanied 
with more or less of the head, the fracture extending along a portion 
of the bicipital groove. 1 

Kobert Smith, however, believes that it was the greater and not the 
lesser tuberosity which was thus detached in the cases mentioned by 
Mr. Guthrie, since the external signs were so nearly like those which 
were present in a woman seen by himself, and in whom an autopsy 
enabled him to verify his diagnosis. The following is the case as 
related by Mr. Smith : — 

" In July, 1844, 1 was requested to examine the body of Julia Darby, 
set. 80, who had died of chronic pulmonary disease. Upon entering 
the room, the appearances of the left shoulder-joint at once attracted 
my attention, and struck me as being different from those which attend 
the more common injuries of this articulation. 

"The shoulder had lost, to a certain extent, its natural rounded 
form; the acromion process, although unusually prominent, did not 
project as much as in cases of dislocation of the head of the humerus. 
The breadth of the articulation was greatly increased, and upon press- 
ing beneath the acromion, an osseous tumor could be distinctly felt, 
occupying the greater part of the glenoid cavity ; it formed a promi- 
nence which was perceptible through the soft parts ; it moved along 
with the shaft of the humerus, but was manifestly not the head of the 
bone. 

" A second and larger tumor, presenting the rounded form of the 

1 Robert Smith, p. 181, from Lond. Med. and Plvys. Journal. 



LONGITUDINAL FKACTUEES OF HEAD AND NECK. 219 

head of the humerus, lay beneath the base of, and internal to, the cora- 
coid process, and between the two the finger could be sunk into a deep 
sulcus, placed immediately below the coracoid process. The elbow 
could be brought into contact with the side, and there was no appre- 
ciable alteration in the length of the arm. 

" Upon removing the soft parts, the head of the bone presented itself, 
lying partly beneath and partly internal to the coracoid process. The 
greater tuberosity, together with a very small portion of the outer 
part of the head of the bone, had been completely separated from the 
shaft of the humerus. This portion of the bone occupied the glenoid 
cavity, the head of the humerus having been drawn inwards so as to 
project upon the inner side of the coracoid process ; it was still, how- 
ever, contained within the capsular ligament. 

"The fracture traversed the upper part of the bicipital groove, 
which, in consequence of the displacement which the head of the bone 
had suffered, was situated exactly below the summit of the coracoid 
process. A new and shallow socket had been formed upon the costal 
surface of the neck of the scapula, below the root of the coracoid pro- 
cess, and the inner edge of the glenoid cavity corresponded to the pos- 
terior part of the sulcus, which separated the head of the bone from 
the detached tuberosity. The latter was united to the shaft only by 
ligament 

"The capsule had not been injured, but was thickened and en- 
larged, and bone had been deposited in its tissue. The injury had 
evidently occurred many years before the death of the patient, but 
the history connected with it could not be precisely ascertained." 1 

Mr. Smith relates one other case, in the living subject, which he 
saw in connection with Mr. Adams, at the Eichmond Hospital, and 
he adds that u numerous" other living examples have fallen under his 
observation. 

Sir Astley Cooper has also published the particulars of a case of 
fracture of the greater tubercle, which was communicated to him by 
Mr. Herbert Mayo. 2 

The following I believe also to have been an example of this rare 
accident : — 

John Hill, set. 78, fell upon the side-walk, striking upon his right 
shoulder. The physician to whom he was sent thought the humerus 
was dislocated, and directed him to the Buffalo Hospital of the Sisters 
of Charity, but he did not apply for admission until eight days after, 
Oct. 14, 1857, when Dr. Boardman and myself examined the limb 
carefully. 

Although we placed him under the influence of chloroform, the 
diagnosis was not satisfactorily made out. We inclined, however, to 
the opinion that it was a fracture of the greater tubercle. The antero- 
posterior diameter of the upper end of the bone was greatly increased; 
there was occasional distinct crepitus, but the limb was not shortened. 

1 Robert Smith, op. cit., p. 178. 

2 A. Cooper, on Dislocations and Fractures of the Joints. Edited by B. Cooper. 
American edition, p. 384. 



220 



FRACTURES OF THE HUMERUS. 



Subsequently, the examinations were repeated many times, and the 
depression between the fragments becoming more palpable, the diag- 
nosis was at length confirmed. 

No treatment was adopted, except confinement in bed, and stimulat- 
ing embrocations. Two months after the accident he still remained 
an inmate of the hospital, his shoulder being quite stiff) and the pro- 
jection continuing in front. 

Mr. Eobert Smith thinks that when the displacement is considerable 
the fragments generally unite by ligament rather than by bone. 



Fig. 58. 



§ 4. Fractures through the Surgical Neck. {Including Separations at 
the Upper Epiphysis.) 

I have already defined the " Surgical Neck" as all of that narrow 
portion commencing at the upper epiphysis and terminating at the 
insertion of the pectoralis major and latissimus dorsi. It seems 
proper, therefore, that we should include under this division, both 
fractures and separations occurring at the epiphysis, especially since, 
owing to their anatomical relations, they are subject to the same dis- 
placements as fractures occurring half an inch or one inch lower down. 
The capsular muscles, with the exception of the teres minor, having 
no more influence over the lower fragment when a 
separation occurs at the epiphysis, than when a 
separation occurs at any other point of the surgical 
neck. 

A brief description of the plan of development of 
the humerus will enable the reader better to under- 
stand the occasional separation of the epiphysis, both 
at the upper and lower ends of the bone. 

The humerus is originally formed from seven car- 
tilaginous centres, namely, one for the shaft, one for 
the head, one for the greater tuberosity, one for each 
epicondyle, and two for the lower, articulating end 
of the bone. At birth the shaft is ossified in nearly 
its whole length. Between the first and fourth years 
ossification commences in the several centres com- 
posing the upper end of the bone, and they coalesce 
by the end of the fifth year, so as to form a single 
epiphysis, which finally unites with the shaft at 
I about the twentieth year. At the lower end of the 

bone ossification commences in the radial portion of 
the articular surface at the end of two years, in the 
trochlear portion at twelve years, in the internal epi- 
condyle at the fifth year, and in the external epicon- 
dyle at the thirteenth or fourteenth. At the sixteenth 
or seventeenth year all the centres are joined to each 
other, and to the shaft, except the inner epicondyle, 
which does not unite by bone until about the eighteenth 
Gray.)* 68 year. It will be observed, therefore, that although 





FRACTURES THROUGH THE SURGICAL NECK. 221 

ossification commences in the upper epiphysis first, it is the last to 
form bony union with the shaft. 

The following is an account of the only case of separation at the 
upper epiphysis which I have ever recognized : — 

Mike Bovin, set. 13 months, fell sideways from his cradle in Novem- 
ber, 1855. He was taken to an empiric, who called' it a sprain, and 
applied liniments. Three weeks after the accident he was brought 
to me, and I found the arm hanging beside the body, with little or 
no power on the part of the child to move it. There was a slight 
depression below the acromion process, and considerable tenderness 
about the joint ; but the shoulder was not swollen, nor had it been at 
any time. The line of the axis of the bone, as it hung by the side, 
was directed a little in front of the socket. 

On moving the elbow backwards and forwards, the upper end of the 
shaft moved in the opposite directions with great freedom, and could 
be distinctly felt under the skin and muscles. This motion was 
accompanied with a slight sound, or sensation, a sensation not like 
the grating of broken bone, but much less rough. There was no short- 
ening of the limb. When the elbow was carried a little forwards 
upon the chest the fragments seemed to be restored to complete coap- 
tation ; and of this I judged by the restoration of the line of the axis of 
the shaft to the centre of the socket, and by the complete disappear- 
ance of the depression under the point of the acromion process. 

I applied suitable dressings to retain the arm in this position; but 
five months after the injury was received the fragments had not united, 
and the child was still unable to lift the arm, although the forearm 
and hand retained their usual strength and freedom of motion. The 
same crepitus could occasionally be felt in the shoulder, and the same 
preternatural mobility. The shoulder was at this time neither swollen 
nor tender. 

Robert Smith and Sir Astley Cooper both speak of it as a frequent 
accident in early life, but the recorded cases are very few. The case 
mentioned by Mr. Smith has been given very much at length, and, as 
a characteristic example, deserves to be repeated : — 

" During the early part of last year, a boy, eight years of age, was 
admitted to the Richmond Hospital, under the care of Dr. McDowell. 
About a week previous to' his admission he had fallen upon the shoul- 
der, and at once lost the power of using his arm. 

" It was at first sight evident that there did not exist any luxation 
of the head of the humerus, and it was equally obvious that the case 
was not an example of any of the ordinary fractures to which the neck 
of the bone is liable. There was no diminution of the natural rotundity 
of the shoulder nor any unusual prominence of the acromion process ; 
the head of the bone could be distinctly felt in the glenoid cavity, and 
it remained motionless when the arm was rotated ; there was very lit- 
tle separation of the elbow from the side, but it was directed slightly 
backwards. 

" About three-quarters of an inch below the coracoid process there 
existed a remarkable and abrupt projection, manifestly formed by the 
upper extremity of the shaft of the humerus, every motion imparted 



222 



FEACTUPwES OF THE HUMERUS. 



Fig. 59. 



to which it followed. Its superior surface, which could be distinctly 
felt, was slightly convex, and its margin had nothing of the sharpness 
which the edge of a recently broken bone presents in ordinary fractures. 
" When this projecting portion of the bone was pushed outwards, so 
as to bring it in contact with the under surface of the head of the 
humerus (previously fixed as far as it was possible to do so), a crepitus 
was produced by rotating the shaft of the bone. It did not, however, 
resemble the ordinary crepitus of fracture, but it would be extremely 
difficult, by any description, to convey a clear idea of what the differ- 
ence consisted in. 

" From a careful consideration of the symptoms and appearances 
above mentioned (taking into account also the age of the patient), the 
diagnosis was formed, that the injury consisted in a separation of the 
superior epiphysis of the humerus from the shaft of the bone. Various 
mechanical contrivances were employed in this case, but all proved 
ineffectual in maintaining the fragments in their proper relative posi- 
tion." 1 

Sir Astley Cooper has also briefly described one example. 
" Its age was ten years. The symptoms of the injury were, inability 
of moving the elbow from the side, or of supporting the arm, unless 

hy the aid of the other hand, without great 
pain. The tension which succeeded filled 
up the hollow which was at first produced 
by the fall of the deltoid muscle. "When 
the head of the bone was fixed, the frac- 
tured extremity of the humerus could be 
tilted under the deltoid muscle, so as to be 
felt, and even shown, by raising the arm at 
the elbow. Crepitus could be perceived, 
not by rotating the arm, but by raising the 
bone and pushing it outward. The cause 
of the fracture was a fall upon the shoulder 
into a saw-pit of the depth of eight feet.' 12 
It will be necessary, in order to a full 
understanding of the various aspects of this 
fracture — a fracture of the surgical neck — 
to relate several illustrative examples. 

Case 1. Simjile fracture ; never displaced. 
Union without deformity. — Alex. Balentine, 
93t. 62 ; admitted to the Buffalo Hospital of 
the Sisters of Charity, December 19, 1851. He had fallen upon the 
side-walk, striking upon his right arm. Dr. Johnson, of Buffalo, had 
reduced the fracture and applied appropriate dressings. ISTo union of 
the fragments had yet occurred ; but as the surfaces were in apposition, 
it was only after considerable manipulation, and not until we bent the 
forearm upon the arm, and rotated the humerus by means of the fore- 
arm, that the crepitus became distinct, and gave unequivocal evidence 
of the existence of a fracture, and of its situation. 




Fracture of the surgical neck of the 
humerus. (From Gray.) 



Robert Smith, op. cit., p. 201. 



2 A Cooper, op. cit., 3S2. 



FRACTURES THROUGH THE SURGICAL NECK. 223 

The treatment, after admission, consisted in the application of one 
gutta-percha splint, accurately moulded, and extending from above the 
shoulder to below the elbow, and encircling one-half the circumference 
of the arm ; the splint being secured with the usual bandages, &c. 

The result is a perfect limb. 

Case 2. Simple fracture. Union with displacement and deformity. — 
White, of Buffalo, set. 12, fell fourteen feet, striking on the front and 
outside of the left shoulder. Dr. P., of Erie County, saw the lad within 
three hours (July 19, 1853). He was brought to me on the fourth day 
after the accident. The upper part of the arm was then very much 
swollen. I found the arm dressed as for a fracture of the middle or 
lower third of the humerus. It was shortened one inch. The elbow 
was inclined backwards, and there was a remarkable projection in front 
of the joint, feeling like the head of the bone. The hand and arm 
were powerless. I suspected a dislocation of the head of the humerus 
forwards ; and, having administered chloroform, I attempted its reduc- 
tion with my heel in the axilla. While making extension, I felt a 
sudden sensation like the slipping of the bone into its socket, but on 
examination I found the projection continued as before. I then re- 
peated the effort, with precisely the same result. 

I now applied an arm sling, and directed leeches and cold evapo- 
rating lotions. 

On the 25th, five days after the accident, it was examined by Drs. 
Mixer, McGregor, Joseph Smith, with myself. We still believed it 
was a dislocation, and having administered chloroform, we again 
attempted its reduction. The same slipping sensation was produced 
as before, and the deformity was repeatedly made to disappear ; but, 
on suspending the extension, it as often reappeared. 

The character of the accident was now made apparent, and we pro- 
ceeded at once to apply the splint and bandages suitable for a fracture 
of the surgical neck of the humerus, namely, a gutta-percha splint, 
extending, on the outside, from the top of the shoulder to below the 
elbow, with an arm and body roller secured with flour paste. 

On the 31st, twelve days after the accident, Dr. Wilcox, Marine Sur- 
geon at Buffalo, saw the arm with me. The fragments were displaced 
the same as when I first saw it, and the same as when no apparatus 
was applied. We examined it again carefully, and attempted to make 
the fragments remain in place, but we were unable to do so, except 
while holding them and making extension. 

August 9 (twenty-first day. I removed all the dressings. Motion 
between the fragments had ceased, but the projection and shortening 
remained as before ; now, also, the irregular projections of the fractured 
bones were more distinctly felt. The dressings were never reapplied. 
Three months later no change had occurred. He could carry the 
elbow forwards freely, as well as backwards, the motions of the shoul- 
der-joint being unimpaired. 

Case 3. Simple fracture, with displacement; resulting in deformity 
and non-union. — L. B., of Lockport, set. 43, was thrown from his horse 
in February, 1854, striking upon his right elbow. 

Dr. Maxwell, an experienced surgeon of Lockport, examined and 



224 FEACTUKES OF THE HUMERUS. 

dressed the fracture. Dr. Fassett was present and assisted at a subse- 
quent dressing. Three surgeons who examined the arm before Dr. 
M., called it a dislocation. 

Twelve weeks after the accident, Mr. B. called upon me. The right 
arm was shortened one inch ; the elbow hung off slightly from the 
body ; the upper end of the lower fragment was distinctly felt in front 
of the shoulder-joint under the clavicle, feeling very much like the 
head of the bone. The fragments were not united, but they could be 
seized easily, and made to move separately and freely. He stated to 
me that he was subject to rheumatism, and especially in the shoulder 
and arm of the side injured. He wished to know whether it could 
not be " re-set." 

Two years after, I found the bone still ununited. He was, however, 
able to write with that hand, having first lifted his arm with the other 
hand and laid it upon the table. 

Case 4. Simple fracture, probably impacted ; resulting in deformity. — 
Wm A., of Buffalo, set. 15, fell backwards, June 4, 1855, striking on 
his back and left shoulder. Dr. L. saw it immediately, and, regarding 
it as a dislocation, attempted its reduction. He subsequently repeated 
the attempt. I saw the patient with Dr. L. on the tenth day. The 
arm was shortened one inch and a half. The fragments were displaced 
forwards, projecting in front of and a little below the joint. As in 
Case 3, it might easily be mistaken for the head of the bone ; but the 
difficulty of diagnosis had been very much lessened by the subsidence 
of the swelling. There was no motion between the fragments ; nor 
could the deformity, by any manipulation or extension, be made to 
disappear. It was probably impacted. 

March 23, 1856, nearly ten months after the accident, I found the 
fragments remaining as when I first examined the limb, and the arm 
shortened one inch and a half. The elbow hung a very little back 
from the line of the body. The upper end of the lower fragment was 
lifted to within one inch of the head of the humerus ; the upper frag- 
ment having its head in the socket, with its lower end downwards and 
forwards. The arm was, however, in every respect as useful as before 
it was broken. It was equally strong, and he could raise his arm as 
high, and move it in every direction as freely, as he could the other. 

Causes. — Epiphyseal separations belong almost exclusively to child- 
ren, but true fractures at the surgical neck occur most often in adult 
life ; with the exception of one girl and two lads, aged, respectively, 
eleven, twelve, and fifteen years, all of the examples of this latter 
accident seen by me occurred in adults, and of twenty -eight cases in 
which I find the ages recorded, the average age is about forty-three 
years ; yet Sir A. Cooper declares these fractures to be most common 
in infancy, while Malgaigne has never seen a case in a person under 
fifty -three years. 

Both epiphyseal separations and fractures at this point are oc- 
casioned, in most cases, by direct blows or falls upon the shoulder. 
Of twenty-seven examples in which I find the cause recorded, eighteen 
were from direct blows, eight from indirect blows, and one from muscu- 
lar action, as in throwing a ball. Of the eight resulting from indirect 



FRACTURES THROUGH THE SURGICAL NECK. 225 

blows, one was from a fall upon the hand, seen by Desault, and seven 
were from falls upon the elbow, of which two were seen by Desault, 
and five by myself. 

Pathology. — I have found the fragments sensibly displaced in ten 
cases out of fifteen ; a proportion much greater than has been observed 
by Malgaigne, who has only seen a displacement twice in more than 
twenty cases. It is certain, however, that complete or sensible dis- 
placement is less common in this fracture than in most other fractures, 
the broken ends being retained in place, probably, by the long tendon 
of the biceps. 

As to the direction of the displacement, I have seen the upper end 
of the lower fragment drawn forwards and upwards toward the cora- 
coid process four times, in one of which examples the upper fragment 
plainly followed in the same direction. Sir Astley Cooper declares 
that with infants this direction is constant, and in museum specimens 
I have seen but one exception. In the specimens of fracture of the 
surgical neck, with also displacement of the head, belonging to Dr. 
Pope, this direction of the fragments is plainly seen, as also in a spe- 
cimen belonging to Dr. Neill, of the Pennsylvania Medical College, 
where the lower fragment almost reaches the coracoid process, and in 
a specimen contained in one of the cabinets of the University of 
Pennsylvania, where the upper end of the lower fragment has become 
united by bone to the coracoid process. 

The only exception which I have met with is in the possession of 
Dr. Neill. In this example the two ends are tilted toward the axilla. 
In the recorded examples, also, I find the displacement forwards men- 
tioned four times, and the displacement toward the axilla but once. I 
am compelled, therefore, to doubt the accuracy of Malgaigne's obser- 
vations, who thinks he has seen the lower fragment most often drawn 
toward the axilla, as well as the observations of those who think that 
the upper fragment is generally displaced outwards; yet, no doubt, 
they do sometimes assume this position. Desault has seen them both 
thrown backwards ; while Dupuytren, Paletta, and others have seen 
them pushed outwards ; and I have in my cabinet the copy of a speci- 
men in which both fragments are drawn outwards, but the lower frag- 
ment is to the inner side of the upper. 

When the fracture occurs at or near the epiphysis, it is sometimes 
accompanied with impaction, of the same character as we have already 
described when speaking of fractures through the tubercles. Robert 
Smith has given, in his treatise, an engraving intended to illustrate 
the relative position of the fragments in extra-capsular impacted frac- 
tures, and the line of separation very nearly corresponds to the line of 
junction of the epiphysis with the shaft. 

But in a majority of cases no impaction occurs. Dr. Charles A. 
Pope, of St. Louis, Mo., has two specimens of this kind, in which no 
union has taken place, nor is there any evidence that impaction had 
ever occurred. In one case the line of fracture commences at the 
junction of the head with the shaft, and extends thence irregularly 
across to a point half an inch below the greater tuberosity. In the 
second specimen the fracture commences at the same point and ter- 



226 FRACTURES OF THE HUMERUS. 

minates three-quarters of an inch below the greater tuberosity. In 
relation to these bones, Dr. Pope remarks: "These are not cases of 
detachment of the epiphyses, as the bones are evidently those of adults, 
and there is, at their lower extremities above the condyles, no trace of 
an epiphyseal line." 

Results. — Eight of the examples of fracture of the surgical neck seen 
by me are known to have resulted in perfect limbs, and three are more 
or less deformed. In one of these no bony union has taken place 
after the lapse of two years or more. It is satisfactory, however, to 
know that, with the exception of this last (Case 3), all the patients 
have recovered the free and complete use of their arms. 

Symptoms, or Differential Diagnosis of Accidents about the Shoulder - 
joint. — No place could be more appropriate than this to call attention 
to the difficulty of diagnosis in the case of accidents about the shoul- 
der-joint, a difficulty which surgeons have constantly recognized, and 
which has sometimes rendered diagnosis impossible. 

In presenting an epitome of the prominent diagnostic signs, I would 
refer the reader who seeks further information to my report to the 
American Medical Association, where the subject is treated more 
elaborately than is consistent with the design of the present volume. 

Let us first study the ordinary signs of a dislocation at the shoulder- 
joint, regarding this as the type with which the other accidents are to 
be compared. 

a. Signs of a Dislocation. {Cause, generally a fall upon the elbow or 
hand.) 

1. Preternatural immobility. 

2. Absence of crepitus. 

3. "When the bone is brought to its place it will remain without the 
employment of force. 

These three are common signs, which apply to any other joint as 
well as the shoulder. 

4. Inability to place the hand upon the opposite shoulder, or to 
have it placed there by an assistant, while at the same time the elbow 
touches the breast. This is a sign common to all of the dislocations 
of the shoulder. 1 

The following are special signs, or such as belong only to particular 
dislocations- of the shoulder. 

5. Depression under the acromion process ; always greatest under- 
neath the outer extremity, but more or less in front or behind, accord- 
ing as the dislocation may be into the axilla, forwards or backwards. 

6. Pound, smooth head of the bone felt in its new situation, and 
very plainly removed from its socket; moving with the shaft. Ab- 
sence of the head of the bone from the socket. 

7. Elbow carried outwards, and in certain cases forwards or back- 
wards, and not easily pressed to the side of the body. 

8. Arm shortened in the dislocation forwards, and slightly length- 
ened when in the axilla. 

1 Report on a New Principle of Diagnosis in Dislocations of the Shoulder-joint, hy 
L. A. Dugas, Prof, of Surgery in the Medical College of Georgia. Trans. Arner. Med. 
Assoc, vol. x. p. 175. 



DIFFERENTIAL DIAGNOSIS OF ACCIDENTS. 227 

b. Signs of a Fracture of the Neck of the Scapula. {Cause, generally 
a direct blow.) 

1. Preternatural mobility. 

2. Crepitus, generally detected by placing the ringer on the coracoid 
process and the opposite hand upon the back of the scapula, while the 
head of the humerus is pushed outwards and rotated. 

3. "When reduced it will not remain in place. 

4. The hand may generally, but with difficulty, be placed upon the 
opposite shoulder, with the elbow resting upon the front of the chest. 

5. Depression under the acromion process, but not so marked as in 
dislocation. 

6. Head of the bone may be felt in the axilla, but less distinctly than 
in dislocation. Never much forwards or backwards. Head of the bone 
moves with the shaft. Head of the bone not to be felt under the acro- 
mion process, although it has not left its socket. 

7. Elbow carried a little outwards, but not so much as in dislocation. 
Easily brought against the side of the body. 

8. Arm lengthened. 

9. The coracoid process carried a little toward the sternum, and 
downwards. 

10. Pressing upon the coracoid process it is found to be movable, 
and it is also observed that it obeys the motions of the arm. 

c. Signs of Fracture of the Anatomical Neck of the Humerus. Intra- 
capsular. {Cause, a direct blow; generally opening to the joint, but 
not always.) 

1. Mobility not increased, nor diminished. 

2. Crepitus, generally discovered by pressing up the head of the 
bone into its socket and rotating; or, when the tubercles are also 
broken, by grasping the tubercles and rotating the arm. 

3. Fragments not generally displaced. 

4. The hand can be placed easily upon the opposite shoulder, with 
the elbow against the front of the chest. 

5. Very slight, if any, depression under the acromion process. 

6. Head of the bone generally in its socket, but not felt so distinctly 
as before the fracture. 

7. Elbow falls easily against the side of the body, or is easily placed 
there. 

8. Arm not lengthened, nor appreciably shortened, unless the head 
be driven so much into the body as to separate the tubercles. 

9. In this latter case there are present also the signs of fracture of 
the tubercles. 

d. Signs of Fracture of the Humerus through the Tubercles. Extra- 
capsular. {Cause, direct blows.) 

1. Generally, there is neither marked mobility nor immobility, ex- 
cept what immobility may be due to a contusion of the muscles. 

2. Crepitus, discovered, but not so easily as in intra-capsular frac- 
tures, by rotating the arm while the tubercles are grasped firmly. 

3. If displacement exists, the fragments are not always easily kept 
in place when once reduced. 



228 FRACTURES OF THE HUMERUS. 

-i. The "hand can be placed upon the opposite shoulder, with the 
elbow against the front of the chest. 

5. No depression under the acromion process. 

6. Head of the bone in its socket, and moving with the shaft, when ; 
as is usually the case, it is impacted. 

7. Elbow hangs against the side of the body. 

8. Arm shortened when impacted, but not very appreciably. 

The signs which characterize this accident are more obscure than in 
either of the other shoulder accidents. They are mostly negative, and 
will not generally be determined positively except in the autopsy. 

e. Signs of a Longitudinal Fracture of the Head and Neck, or splitting 
off of the Greater Tubercle. (Cause, direct blow upon the front of the 
shoulder.) 

1. Mobility of the limb natural. 

2. Crepitus ; elicited especially by grasping the tubercles and rotat- 
ing the arm, or by carrying it up and back and then rotating. 

3. When reduced, the fragments will not remain in place. 

4. The hand can be placed upon the opposite shoulder, while the 
elbow rests against the front of the chest. 

5. Some depression under the acromion process. 

6. A smooth bony projection directly underneath the coracoid pro- 
cess, or close upon its inner or outer side, moving with the shaft. The 
head of the bone cannot be felt in the socket, yet the space under the 
acromion is not entirely unoccupied. 

7. G-enerally, but not always, the elbow hangs against the side. 
Sometimes it inclines a little backwards. It can always be easily 
brought to the side. 

8. Arm generally neither lengthened nor shortened. 

9. A remarkable increase in the antero-posterior diameter of the 
upper end of the bone. 

10. A deep vertical sulcus between the tubercles, corresponding with 
the upper part of the bicipital groove. 

f. Signs of a Fracture through the Surgical Neck. (Cause, generally, 
direct blows.) 

1. Preternatural mobility often, but not constantly present. 

2. Crepitus, produced easily when there is no impaction, or when 
the displacement is not complete, but with difficulty when impaction 
exists or the displacement is complete. 

3. When once the fragments have been displaced, it is exceedingly 
difficult ever afterward to maintain them in place. 

4. The hand can be easily placed upon the opposite shoulder, while 
the elbow rests against the front of the chest. 

5. A slight depression below the acromion, not immediately under- 
neath its extremity, but an inch or more below. 

6. Head of the bone in the socket, and moving with the shaft when 
impacted, but not moving with the shaft when not impacted. The 
upper end of the lower fragment being often felt distinctly pressing 
upwards toward the coracoid process; its broken extremity being 
easily distinguished by its irregularity from the head of the bone. 



DIFFERENTIAL DIAGNOSIS OF ACCIDENTS. 229 

7. Elbow hanging against the side when the fragments are not dis- 
placed, but awaj from the side when displacement exists. 

8. Length of arm unchanged unless the fragments are impacted or 
overlapped ; or both fragments are much tilted inwards. If the frag- 
ments are completely displaced, the arm is shortened. 

g. Signs of a Separation at the Epiphysis. (Cause, direct blows.) 

1. Preternatural immobility. 

2. Feeble crepitus; less rough than the crepitus produced when 
broken bones are rubbed against each other. 

3. Fragments replaced are not easily maintained in place. 

4. Same as in preceding variety of fracture. 

5. The depression is not immediately under the acromion, yet higher 
than in most fractures of the surgical neck, perhaps one inch below 
the acromion process. 

6. Head of the bone in its socket, and not moving with the shaft. 
Upper end of lower fragment projecting in front, when displacement 
exists, and feeling less sharp and angular than in case of a broken 
bone; indeed, being slightly convex and rather smooth, it may easily 
be mistaken for the head of the bone. 

7. Same as in preceding variety. 

8. Length of arm not changed unless the fragments are overlapped, 
or both fragments are tilted upon each other. When the fragments 
are overlapped, the arm is shortened. 

9. This accident is almost peculiar to infancy and childhood. It 
can seldom occur after the twentieth year. 

There are other accidents about the shoulder-joint such as a patho- 
logical partial luxation- of the humerus, dislocation of the tendon of 
the biceps, &c, which might possibly be confounded with fractures, 
but the consideration of which I shall reserve for another time. 

Treatment. — I have already spoken of the treatment of fractures of 
the neck of the scapula, and my remarks will now be confined to 
fractures of the upper end of the humerus. 

Fractures of the Anatomical Neck; Intra- capsular. — As hac* already 
been stated, these are generally compound fractures, and from the 
extent of the injury often demand resection or amputation of the 
entire arm. If an effort is made to save the arm, splints will not be 
applied, and the treatment will have little or no reference to the 
existence of a fracture ; it will be directed only to the reduction or 
prevention of the inflammation, &c. 

Simple fracture of the anatomical neck, without any external wound 
communicating with the joint, and accompanied, as it often is, with 
impaction, frequently unites, or the upper fragment becomes encased 
in the lower. 

It is not proper in such cases to employ great violence for the pur- 
pose of detecting crepitus, lest the fragments should become displaced ; 
and if the arm should be found to be a little shortened, it must not be 
extended, with a view to overcoming the shortening, since upon the 
impaction probably depends, in a great measure, the chances of union. 

The elbow and forearm may be suspended in a sling, while the arm 



230 FRACTURES OF THE HUMERUS. 

is gently supported against the side, merely to insure quietude. No 
splints are necessary or useful. 

Treatment of Fractures through the Tubercles [Extra- capsular) ; Non- 
impacted and Impacted. — In these cases, also, the fragments being 
seldom displaced, very little if any mechanical treatment is demanded. 
A sling is all that is usually required. If, however, on account of dis- 
placement of the fragment, a splint is thought necessary, it must be 
applied in the manner hereafter to be directed in cases of fractures of 
the surgical neck. 

If impaction, with shortening, exists, the same remarks are appli- 
cable here as in intra-capsular impacted fractures, namely, that we 
ought not to rotate the limb much, nor violently, in order to discover 
crepitus, nor make extension with the view of overcoming the short- 
ening since the fragments unite more promptly and certainly when 
the impaction remains, and its continuance in no way damages the 
usefulness of the limb. 

Treatment of Longitudinal Fractures of the Head and Neck, or of a 
Separation of the Greater Tubercle. — In the only instance which I have 
recognized as a fracture of the greater tubercle, and already referred 
to, the displacement was moderate, and could not be overcome either 
by change of position or by pressure with extension. The patient 
was therefore merely laid upon his back in bed. No dressings of any 
kind were employed, and the fragments seemed to unite promptly, 
and with no increase in the displacement. 

If the displacement is originally more considerable, attempts ought 
still to be made to reduce the fragments, by extension and abduction 
of the arm, with direct pressure; yet they will not generally prove 
completely successful, nor will it be found easy to retain them when 
reduced. 

Mr. Mayo treated a fracture of this character, which occurred in a 
man of sixty years of age, with a flgure-of-8 bandage, and a sling, with 
a lathe splint on the outer side of the humerus, the upper part of 
which was made to bear on the fragments, by uniting the upper part 
of the circular arm roller to the flgure-of-8 bandage. " The fracture 
united favorably," he says, but we presume that he does not mean to 
affirm that it united without any degree of displacement; a result 
which, probably, ought never to be expected. Mr. Mayo adds, how- 
ever, that " for a long time the patient had some difficulty in carrying 
the arm backward." 1 

Treatment of Fractures of the Surgical Neck, including Separations at 
the Epiphysis. — I see no reason to suppose that the indications of treat- 
ment can essentially vary in separations at the epiphysis, from those 
in true fractures through any part of the. surgical neck, since the rela- 
tive action of the muscles remains the same, and the direction of the 
displacement is generally the same. My remarks, therefore, upon this 
point may be considered as equally applicable to fractures and epiphy- 
sary separations. 

In a considerable proportion of these cases not much displacement 

1 B. Cooper's edition of Sir A. Cooper on Dislocations, &c, American edition, p. 835. 



FRACTURES THROUGH THE SURGICAL NECK. 231 

of either fragment takes place, and consequently we have only to apply 
such moderate retentive means as will insure quiet. Indeed, under 
such circumstances we might not hesitate to adopt the posture treat- 
ment practised by Dupuytren in two cases, both of which terminated 
favorably. The treatment consisted in placing the arm, semi-flexed, 
on a pillow, the pillow being arranged so as to form a pyramid, the 
summit of which was lodged in the axilla, while the elbow was se- 
cured to the side of the body by a bandage. 1 

Unhappily, however, as we have seen, this condition is not always 
present ; the most frequent form of displacement being that in which 
the lower fragment is drawn upwards and inwards, or towards the 
coracoid process. 

In such cases it will require, often, no little perseverance and skill 
to effect reduction, if it is not found to be actually impossible, and 
still more to retain the bones in place when once reduced. Indeed, 
it is proper to say that a complete reduction is seldom accomplished 
and permanently maintained, owing, probably, to the advantageous 
action of the muscles which tend to produce the displacement, and in 
part also to the difficulty of applying any apparatus or dressing which 
shall act efficiently upon the fragments. 

Sir Astley Cooper recommends for this accident a couple of splints, 
to be placed one in front of and one behind the shoulder, an axillary 
pad, a clavicular bandage, and a sling ; the sling being made to sus- 
pend only the wrist and not the elbow, since he had observed that 
when the elbow was lifted the upper end of the shaft was inclined to 
fall forwards. 

Mr. Tyrrell informed Mr. Cooper that in a similar case he had found 
the bone best maintained in its natural position by its being raised 
and supported at right angles with the side, by a rectangular splint, a 
part of which rested against the side, while the arm reposed upon the 
other part; and until he had made use of this plan, he could not 
succeed in removing the deformity, or in keeping the bone in its 
place. 

Mr. Erichsen has found a very convenient apparatus to consist of 
" a leather splint about two feet long by six inches broad, bent upon 
itself in the middle, so that one-half of it may be applied lengthwise 
to the chest, and the other half to the inside of the injured arm, the 
angle formed by the bend, which should be somewhat obtuse, being 
well pressed up into the axilla." 

The following is the plan which I would, however, generally re- 
commend: — 

The fragments having been reduced as completely as possible, a 
broad and firm gutta-percha splint should be moulded to the outside 
of the arm and shoulder. When it has become sufficiently hard and 
firm, it may be secured in place by a roller carried from the elbow to 
the axilla. If the splint covers well the top of the shoulder, and is 
sufficiently wide, it is not apt to become displaced ; and by resting 
against the point of the acromion process, it enables the upper turns 

1 Dupuytren on Bones, Sydenham edition, p. 99. 



232 



FRACTURES OF THE HUMERUS, 



Fig. 60. 



of the bandage to draw the broken end of the lower fragments out- 
wards ; at least, as effectually as any other dressing is capable of doing, 
and renders an axillary pad unnecessary. The sling may then be 
applied as recommended by Sir Astley Cooper, or the arm may be 
permitted to hang perpendicularly beside the body. The clavicular 
bandage, also recommended by Sir Astle} 7- , complicates the dressing 
very much, and does not seem to me to answer any 
very useful purpose; while the axillary pad exposes 
the brachial plexus to painful if not injurious pressure. 
As a substitute for gutta-percha, a firm sheet of felt 
may be employed, a piece of sole leather or a carved 
wooden splint, or the very complete shoulder and arm 
splint of Welch ; but in either case the upper portion 
of the splint ought always to rest upon the shoulder, so 
as to prevent its sliding downwards. 

Dr. Waters read before the ^Esculapian Society of 
the University of New York, a remarkable case of 
compound and comminuted fracture of the shaft and 
surgical neck of the humerus, in which the constant 
protrusion of the upper end of the middle fragment in 
the region of the axilla finally rendered resection of the 
head and neck necessary. This operation was made by 
Dr. Waters, on the eighteenth day ; and four months 
after, the patient was so far recovered as to be able to 
write a letter with the limb upon which the operation 
had been made. 1 It may be regarded, therefore, as a 
signal triumph of conservative surgery, since the alternative presented 
was only between amputation and resection. In a similar case, Dr. 
W. H. Yan Buren, of New York, was compelled to amputate at the 
shoulder-joint, after which the patient made a good recovery. 2 




Welch's shoul 
der splint. 



§ 5. Shaft, below the Surgical Neck and above the Base of the 

Condyles. 

Causes. — In a record of nineteen cases in which the cause of the frac- 
ture is stated, I find this portion of the shaft broken from direct violence 
twelve times; from indirect blows, the concussion being received upon 
the elbow, twice ; once it was a consequence of tertiary lues, once it 
occurred during birth, and three times in the same patient it has been 
broken from muscular action alone, each consecutive fracture occur- 
ring at a different point. The records of surgery furnish many ex- 
amples of fracture of the shaft of the humerus from muscular action, 
as in throwing a stone or snowball ; but the most singular examples 
are those in which the bone has been broken in a trial of strength 
between two persons, by grasping the hands palm to palm, with the 
elbows resting upon a table, and twisting, when the humerus has sud- 



' ^Waters, New York Journal of Medicine, May, 1S47, p. 318, vol. viii. First Series. 
2 Van Buren, ibid., January, 1854, p. 152, vol. xii. Second Series. 



SHAFT BELOW THE SURGICAL NECK. 233 

denly given way a little above the condyles. This practice is called 
by the French "tourner poignet" the game of turning wrists. I have 
seen one case of this kind, which was under the care of Dr. Winne, 
and Malgaio-ne has collected five other similar cases, two of which 
were reportd by Lonsdale. In U Union Medicale is reported an ex- 
ample in which the fracture occurred on a level with the insertion of 
the deltoid, a little below the insertion of the pectoralis major and 
latissimus dorsi. The fracture seemed to be nearly transverse. 1 

The example of fracture during birth, to which I have referred, oc- 
curred in a healthy female child, whose parents were also healthy. 
The mother was in labor six or eight hours, but the labor was not 
severe. She was attended by a midwife, and does not know whether 
violence was employed or not. Dr. Lockwood, of Buffalo, was called 
on the third day, and found the arm broken a little below its middle, 
and moving as freely as it did at the elbow-joint ; he applied lateral 
splints with bandages, &c. I saw the child with Dr. Lockwood on 
the seventeenth day after its birth. There was then a perfect ferule 
of ensheathing callus surrounding the fragments, and which, owing to 
the softness of the flesh, could be easily detected and defined. The 
fragments had been firm at least three or four days. Nearly a year 
after, I again examined the arm, and could not discover any traces of 
the accident. 

Dr. Lowenhardt has also reported a case in which the evidence was 
conclusive that the fracture was caused solely by the contractions of 
the uterus, which forced the arm against the pubes ; the arm being 
heard distinctly to snap when it was passing this point, and while the 
hands of the accoucheur were not aiding in the delivery. In this case 
the humerus was broken in its upper third. 2 

Seat and Direction of the Fracture. — The seat of the fracture is more 
often below than above the middle of the bone ; thus I have found the 
fracture fourteen times near the middle, and the same number of times 
below the middle third, but only seven times above the middle third. 
The observations of Norris, who found four fractures of the shaft 
above the middle, and nine below, correspond with my own; 3 but 
M. Gueretin, in the same number of fractures, found nine above the 
middle and four below. 4 

The line of fracture is generally oblique, but more often transverse 
than in fractures of the clavicle, femur, or tibia. 

Displacement — The direction of the displacement depends, no doubt, 
sometimes upon the precise point of the fracture and upon the action 
of the muscles operating upon the two fragments; thus, if the fracture 
takes place just above the insertion of the deltoid, the lower fragment 
is liable to be drawn upwards and outwards, in the direction of its 
fibres, while the upper fragment is carried toward the origin of the 
pectoralis major, &c; but, in a great majority of cases, the influence 

1 Amer. Med. Times, vol. iv. p. 153. 

2 Lowenhardt, American Journal of Medical Sciences, January, 1841, p. 250, from 
Medicin Zeit., Mai 6, 1840. 

3 Norris, Am. Journ. of Med. Sci., January, 1842, vol. xix. p. 28. 

4 Gueretin, Presse Medicale, vol. i. p. 45. 

16 



234 FKACTUKES OF THE HUMERUS. . 

of these muscles is more than counterbalanced by the direction of the 
force, and by the direction of the fracture. Practically, therefore, it is 
seldom of much importance to determine the exact point of fracture, 
as to whether it is just above or below the insertion of a particular 
muscle ; nor, indeed, is it generally very easy to ascertain this point 
with much precision. 

The amount of displacement varies considerably in different persons, 
and in fractures at different points, but it will average about three- 
quarters of an inch. When the fracture is produced by muscular 
action alone it is generally transverse, and displacement seldom occurs. 
Such was the fact in every instance where my own patient broke the 
arm three times consecutively at different points; and union was 
speedily accomplished, and with no deformity. Dupuytren, however, 
saw a case which constituted an exception to this general rule. The 
fragments became completely separated, and were so movable that 
union could not be effected, and he was compelled, after three months, 
to resort to resection. 

Results. — In twenty- three examples, the average shortening is about 
one-quarter of an inch ; but of these, thirteen are not shortened at all, 
so that the average of shortening in the remaining ten is three-quar- 
ters of an inch ; the amount of overlapping varying from one-quarter 
of an inch to one inch and a quarter. 

In forty-five examples, not including gunshot fractures, I have three 
times seen the humerus refuse to unite by bone ; once when the fracture 
was in the lower third of the shaft. This was an oblique, compound frac- 
ture, and no union had taken place at the end of five months. The 
man was intemperate, but in pretty good health. 1 In the second case, 
the fracture had occurred a little below the middle of the bone, and 
it was simple. Five months after the accident this patient consulted 
me, when I found the elbow anchylosed, the forearm being fixed at 
right angles with the arm. 2 Neither of these patients had been under 
my care previously, but I learned that an intelligent Canadian surgeon 
had treated one of them, and the other had been seen and treated by 
several surgeons. 

In the third case, a lad, five years of age, received a fracture 
about three or four inches above the elbow-joint, by the passage across 
the limb of a heavy army wagon. The arm was dressed with splints, 
and in about five weeks several fragments of necrosed bone were 
removed by Dr. Pope, of St. Louis, and the splints were again applied. 
Ten months from the date of the injury, Dr. Brinton, of Philadelphia, 
operated by perforation, and reapplied splints. When the splints were 
removed, the limb was straight and apparently firm, but the bond of 
union gradually gave way, and when he came under my charge in 
Nov. 1864, more than two years' after the accident, the arm was bent 
at an angle of 45°, and the union was fibrous only. Under my advice 
all restraint and dressings were removed, and he was sent into the 
country to improve his general health, with the understanding that 
I would operate at some future day. 

1 Report on Deformities, &c, Case 33. 2 Ibid., Case 21. 



SHAFT BELOW THE SURGICAL NECK. 



235 



In two other cases, the elbow remained somewhat stiff a long time 
after the splints were removed ; in one case, complete freedom of 
motion was not restored at the end of fifteen years. 

Generally, however, the motions of the elbow-joint have been very 
soon restored after the removal of the splints and sling. 

I ought to mention that, not unfrequently, fractures of the shaft of 
the humerus, and especially where they are occasioned by direct blows, 
are followed by great swelling, and sometimes by abscesses. In one 
instance the fracture having taken place within the insertion of the 
deltoid muscle, the sharp extremity of the lower fragment was made 
to penetrate the flesh, causing an abscess, and finally tetanus, of which 
my patient soon died. 

The following remarks of Malgaigne are too pertinent to be omitted 
in this connection : "When there is great obliquity, with overlapping, 
or a fracture with splintering, or a multiple fracture, a certain amount 
of deformity is inevitable, and the formation of callus demands one or 
two weeks more. With the inflammation comes also the danger of 
suppuration, and later, a rigidity of the articulations difficult to dissi- 
pate. In short, we must not forget that of all fractures, those of the 
humerus are most liable to fail of consolidation." 

On the other hand, we shall find, in the case of this bone, as in all 
others, some remarkable exceptions, where, although the fracture may 
be compound, and badly comminuted, yet the limb has been saved 
and made useful. Ayres, of New York, reports a 
case of this kind, in which he removed a portion 
of the shaft, and although the brachial artery was 
probably obliterated, a good union took place ; x 
Walker, of Boston, has noticed two or three simi- 
lar examples; 2 and many parallel cases have been 
furnished by the experience of the late war. 

Treatment. — In the treatment of fractures of that 
portion of the shaft of the humerus now under 
consideration, I have preferred generally a broad 
and thick splint of gutta percha — felt or sole leather 
may answer nearly as well — sufficiently long to 
extend from the top of the shoulder to the elbow- 
joint, moulded accurately, and applied to the outside 
of the shoulder and arm, while the limb is flexed to 
a right angle, and while extension is beiug made 
upon the humerus. This being properly padded, 
and secured in place by rollers, I place the arm in 
a sling beside the body. The sling must, however, 
be so arranged, by being looped under the wrists, J^t^l""^wl! 
and not under the elbow, as that the weight of the b. shaft, c. Eibowrest. 
elbow and lower part of the arm may aid in making E - Hook for attachment 
extension. Welch's splint will answer the same Z^tTcxo^Tx 
purpose ; or three narrow splints of different lengths the same purp o S e. 




1 Ayres, New York Journal of Medicine, January, 1857, p. 24, 3d series, vol. xi. 

2 Walker: Essay on Compound Fractures, &c, by William J. Walker, of Boston, 
published in London in 1845. 



236 FRACTURES OF THE HUMERUS. 

may be "used, but I do not find them so convenient as "Welch's, gutta 
percha, felt or leather applied as I have directed above. 

Other surgeons have sought to make permanent extension in these 
and certain other fractures of the humerus, by various contrivances. 
Mr. Lonsdale constructed an instrument which might be lengthened 
or shortened to suit the case ; it was made of steel, and was worked 
with a screw operating npon cogs in a sliding bar ; resembling, in 
some respects, the arm portion of Jarvis' adjuster. In the second 
London edition of a series of plates illustrating the action of the 
muscles in producing displacement in fractures, by S. W. Hind, is a 
drawing of an apparatus invented by the author for the same purpose, 
which is very simple, and in some respects more complete than Lons- 
dale's and which may be easily adapted to almost any form of arm- 
splint. Indeed, nothing more is necessary than to attach to the ordi- 
nary long splint a movable crutch. 

I believe that all these contrivances may prove occasionally useful, 
but the common experience of surgeons has shown how difficult it is 
to accomplish much extension by means of pressure in the axilla; a 
mode, too, which I think must be wholly inadmissible when the frac- 
ture approaches the upper end, since the pressure by the crutch-head 
upon the pectoralis major and latissimus dorsi, which constitute the 
margins of the axilla, must tend to displace the fragments upon which 
they act. inwardly, and which seldom can be applied with much force 
to fractures near the condyles, on account of the probable existence of 
inflammation and swelling about the joint. 

Malgaigne, when speaking of the apparatus of Lonsdale, remarks : 
" But the surgeon should never lose sight of the fact that permanent 
extension is a resource always dangerous, often useless, and which 
demands in its application much caution and watchfulness." 

The following example will illustrate the practical difficulty of em- 
ploying permanent extension in fractures of the humerus : — 

A laborer, aged thirty, was admitted into the Buffalo Hospital of the 
Sisters of Charity, on the second day of October, 1853, with a simple 
oblique fracture of the humerus, which had occurred three days before. 
The fracture was situated within the insertion of the deltoid, and hav- 
ing been produced by the rolling of a log upon the arm, the whole 
limb was much swollen. The night following his admission, in a fit 
of delirium tremens, he removed all of the dressings. When I visited 
the wards in the morning, I found the fragments displaced and the 
muscles contracting violently. The ordinary dressings were applied, 
and continued until the fifth day, when, as the delirium had not ceased, 
and the muscles continued to contract with great violence, it was de- 
termined to attempt permanent extension. For this purpose we lifted 
the elbow upwards and outwards, to relax the deltoid, and then, 
having made extension with the forearm placed at a right angle with 
the arm, we fitted carefully a large gutta-percha splint to the forearm, 
arm, axilla, and side, in such a manner that when the splint was 
secured to these several parts, the arm could not fall to the side of the 
body completely, and in proportion as it did fall downward, it would 



SHAFT BELOW THE SURGICAL NECK. 237 

make extension upon the arm. This splint was well padded, and 
secured in place by rollers. 

On the sixth day the delirium had ceased, and never returned. 
The dressings were well in place, and seemed to accomplish the indi- 
cation we had in view ; but, on the seventh day, although he had kept 
very quiet, everything was disarranged, and the whole had to be re- 
adjusted. On the eighth and ninth the same thing occurred. During 
this time we had varied the dressings, position, &c, each day, to meet, 
if possible, the difficulties, but it was at length deemed unwise to pur- 
sue the attempt any further, and we returned to the use of the ordinary 
splints, laying the arm against the side of the body. The union was 
finalty completed without either overlapping or angular displacement. 

Something may always be accomplished when the patient is walking 
about, by allowing the elbow to escape from the sling, so that its 
weight shall make constant traction upon the lower fragment; and the 
plan which I suggested some years since, of treating certain cases of 
delayed union of the humerus, namely, extending the arm at full 
length by the side of the body, so that the lower fragment shall receive 
the whole weight of the forearm and hand, might occasionally prove 
valuable in recent fractures where the tendency to override was very 
great. In three instances, I have already put this plan sufficiently to 
the test to determine its safety and utility. 

The precise plan, and my reasons for its adoption in certain cases of 
delayed union, were set forth in the following paper, read before the 
Buffalo City Medical Association, and published in the Buffalo Medi- 
cal Journal for August, 1854. 

"I have observed that non-union results more frequently after frac- 
tures of the shaft of the humerus, than after fractures of the shaft of 
any other bone. 

"Comparing the humerus with the femur, between which, above all 
others, the circumstances of form, situation, &c, are most nearly 
parallel, and in both of which non-union is said to be relatively fre- 
quent, I find that of forty-nine fractures of the humerus, four occurred 
through the surgical neck, twelve through the condyles, and twenty- 
nine through the shaft. In one of the twenty-nine the patient survived 
the accident only a few days. In four of the remaining twenty-eight, 
union had not occurred after the lapse of six months, and in many 
more it was delayed beyond the usual time. Two of the four were 
simple fractures, and occurred near the middle of the humerus ; the 
third was compound, and occurred near the middle also; the fourth 
was compound, and occurred near the condyles. 

" This analysis supplies us, therefore, with four cases of non-union, 
from a table of twenty-eight cases of fractures through the shaft. 

"Of eighty-seven fractures of the femur, twenty occurred through 
the neck, one through the trochanter major, and one through the con- 
dyles. The remaining sixty-five occurred through the shaft, and 
generally near the middle, and not in one case was the union delayed 
beyond six months. 

"To make the comparison more complete, I must add that of the 
twenty-eight fractures of the shaft of the humerus, six were compound ; 



238 FRACTUEES OF THE HUMERUS. 

and of the sixty-five fractures of the shaft of the femur, six were 
either compound, comminuted, or both compound and comminuted. 
The six compound fractures of the shaft of the humerus furnished two 
cases of non-union. The six cases of either compound or comminuted, 
or compound and comminuted fractures of the femur, furnished no 
case of non-union. 

" I beg to suggest to the Society what seems to me to be the true 
explanation of these facts. 

" It is the universal practice, so far as I know, in dressing fractures 
of the humerus, to place the forearm at a right angle with the arm. 
Within a few days, and generally, I think, within a few hours, after 
the arm and forearm are placed in this position, a rigidity of the mus- 
cles and other structures has ensued, and to such a degree that if the 
splints and sling are completely removed, the elbow will remain flexed 
and firm ; nor will it be easy to straighten it. A temporary false 
anchylosis has occurred, and instead of motion at the elbow-joint, when 
the forearm is attempted to be straightened upon the arm, there is only 
motion at the seat of fracture. It will thus happen that every upward 
and downward movement of the forearm will inflict motion upon the 
fracture ; and inasmuch as the elbow has become the pivot, the motion 
at the upper end of the lower fragment will be the greater in propor- 
tion to the distance of the fracture from the elbow-joint. 

" No doubt it is intended that the dressings shall prevent all motion 
of the forearm upon the arm ; but I fear that they cannot alwaj^s be 
made to do this. I believe it is never done when the dressing is made 
without angular splints, nor is it by any means certain that it will be 
accomplished when such splints are used. The weight of the forearm 
is such, when placed at a right angle with the arm, and encumbered 
with splints and bandages, that even when supported by a sling, it 
settles heavily forwards, and compels the arm-dressings to loosen them- 
selves from the arm in front of the point of fracture, and to indent 
themselves in the skin and flesh behind. By these means the upper 
end of the lower fragment is tilted forwards. If the forearm should 
continue to drag upon the sling, nothing but a permanent forward 
displacement would probably result. The bones might unite, yet with 
a deformity. 

"But the weight of the forearm under these circumstances is not 
uniform, nor do I see how it can be made so. It is to the sling that 
we must trust mainly to accomplish this important indication. But 
you have all noticed that the tension or relaxation of the sling depends 
upon the attitude of the body, whether standing or sitting; upon the 
erection or inclination of the head ; upon the motions of the shoulders ; 
and in no inconsiderable degree upon the actions of respiration. Nor 
does the patient himself cease to add to these conditions by lifting the 
forearm with his opposite hand whenever provoked to it by a sense 
of fatigue. 

" This difficulty of maintaining quiet apposition of the fragments 
while the arm is in this position, at whatever point it may be broken, 
becomes more and more serious as we depart from the elbow-joint, 
and would be at its maximum at the upper end of the humerus, were 



SHAFT BELOW THE SUEGICAL NECK. 239 

it not that "here a mass of muscles, investing and adhering to the bone, 
in some measure obviates the difficulty. Its true maximum is, there- 
fore, near the middle, where there is less muscular investment, and 
where, on the one hand, the fracture is sufficiently remote from the 
pivot or fulcrum to have the motion of the upper end of the lower 
fragment multiplied through a long arm, while, on the other hand, it 
is sufficiently near the armpit and shoulder to prevent the upper 
portion of the splint and arm-dressings from obtaining a secure grasp 
upon the lower end of the upper fragment. 

" It must not be overlooked that the motion of which we speak 
belongs exclusively to the lower fragment, and that it is always in 
the same plane forwards and backwards, but especially that it is not 
a motion upon the fracture as upon a pivot, but a motion of one frag- 
ment to and from its fellow. This circumstance I regard as important 
to a right appreciation of the difficulty. Motion alone, I am fully 
convinced, does not so often prevent union as surgeons have generally 
believed. It is exceedingly rare to see a case of non-union of the 
clavicle. Of forty-seven cases of fracture of the clavicle which have 
come under my observation, and in by far the greater proportion of 
which considerable overlapping and consequent deformity ensued, 
only one has resulted in non-union, and in this instance no treatment 
whatever was practised, but from the time of the accident the patient 
continued to labor in the fields, and hold the plough as if nothing had 
occurred. I have, therefore, seen no case of non-union of the clavicle 
where a surgeon has treated the accident. Indeed, what is most per- 
tinent and remarkable, its union is more speedy, usually, than that of 
any other bone in the body of the same size. Yet to prevent motion 
of the fragments in a case of fractured clavicle with complete separa- 
tion and displacement, except where the fracture is near one of the 
extremities of the bone, I have always found wholly impracticable. 
Wherever bandages or apparatus has been applied, I have still seen 
always that the fragments would move freely upon each, other at each 
act of inspiration and expiration, and at almost every motion of the 
head, body, or upper extremities. It is probable, gentlemen, that you 
have made the same observation. 

" From this and many similar facts I have been led to suspect, for 
a long time, that motion has had less to do with non-union than was 
generally believed. 

"I find, however, no difficulty in reconciling this suspicion with 
my doctrine in reference to the case in question ; and it is precisely 
because, as I have already explained, the motion, in case of a fractured 
humerus, dressed in the usual manner, is peculiar. 

" In a fracture of the clavicle through its middle third (its usual 
situation), the motion is upon the point of the fracture as upon a pivot ; 
although, therefore, the motion is almost incessant, it does not essen- 
tially, if at all, disturb the adhesive process. The same is true in 
nearly all other fractures. The fragments move only upon themselves, 
and not to and from each other. I know of no complete exception 
but in the case now under consideration. 

"Aside from any speculation the facts are easily verified by a per- 



240 FKACTUEES OF THE HUMERUS. 

sonal examination of the patients during the first or second week of 
treatment, or at any time before union has occurred, both in fractures 
of the humerus and clavicle. The latter is always sufficiently exposed 
to permit you to see what occurs, and as soon as the swelling has a 
little subsided in the former case you will have no difficulty in feeling 
the motion outside of the dressings, or, perhaps, in introducing the 
finger, under the dressings sufficiently far to reach the point of fracture. 
I believe you will not fail to recognize the difference in the motion 
between the two cases. Such, gentlemen, is the explanation which I 
wish to offer for the relative frequency of this very serious accident — 
non-union of the humerus. 

"I know of no other circumstance or condition in which this bone 
is peculiar, and which, therefore, might be invoked as an explanation. 
Overlapping of the bones, the cause assigned by some writers, is not 
sufficient, since it is not peculiar. The same occurs much oftener, 
and to a much greater extent, in fractures of the femur, and equally 
as often in fractures of the clavicle, yet in neither case are these results 
so frequent. Nor can it be due to the action of the deltoid muscle, or 
of any other particular muscles about the arm, whether the fracture 
be below or above their insertions, since similar muscles, with similar 
attachments, on the femur and on the clavicle, tending always power- 
fully to the separation of the fragments, occasion deformity, but they 
seldom prevent union. 

'■ If I am correct in my views, we shall be able sometimes to con- 
summate union of a fractured humerus where it is delayed, by straight- 
ening the forearm upon the arm, and confining them to this position. 
A straight splint, extending from the top of the shoulder to the hand, 
constructed from some firm material, and made fast with rollers, will 
secure the requisite immobility to the fracture. The weight of the 
forearm and hand will only tend to keep the fragments in place, and 
if the splint and bandages are sufficiently tight, the motion occasioned 
by swinging the hand and forearm will be conveyed almost entirely 
to the shoulder-joint. Very little motion, indeed, can in this posture 
be communicated to the fragments, and what little is thus communi- 
cated is a motion, which experience has elsewhere shown, not disturb- 
ing or pernicious, but a motion Only upon the ends of the fragments, 
as upon a pivot. 

"I do not fail to notice that this position has serious objections, and 
that it is liable to inconveniences which must always, probably, pre- 
vent its being adopted as the usual plan of treatment for fractured 
arms. It is more inconvenient to get up and lie down, or even to sit 
down, in this position of the arm, and the hand is liable to swell. 
But I shall not be surprised to learn that experience will prove these 
objections to have less weight than we are now disposed to give them. 
Remember, the practice is yet untried — if I except the case which I 
am about to relate, and in which case, I am free to say, these objec- 
tions scarcely existed. The swelling of the hand was trivial, and 
only continued through the first fortnight, and the patient never spoke 
of the inconvenience of getting up or sitting down, or even of lying- 
down. 



SHAFT BELOW THE SUBGICAL NECK. 241 

' " The following is the case to which I have just referred : ' Michael 
Mahar, laborer, set. 35, broke his left humerus just below its middle, 
Dec. 14, 1853. The arm was dressed by a surgeon in Canada West, 
and who is well known to me as exceedingly 'clever.' After a few 
days from the time of the accident, ' the starch bandage was put on 
as tight as it could be borne, and brought down on the forearm, so 
as to confine the motions of the elbow-joint.' Six weeks after the 
injury, Jan. 29, 1854, Mahar applied to me at the hospital. No union 
had occurred. The motion between the fragments was very free, so 
that they passed each other with an audible click. There was little 
or no. swelling or soreness. In short, everything indicated that union 
was not likely to occur without operative interference. The elbow 
was completely anchylosed. I explained to my students what seemed 
to me to be the cause of the delayed union, and declared to them that 
I did not intend to attempt to establish adhesive action until I had 
straightened the arm. They had just witnessed the failure of a pre- 
cisely similar case, in which I had made the attempt to bring about 
union without previously straightening the arm. 

"'On the 6th of Feb. 1854, we had succeeded in making the arm 
nearly straight. I now punctured the upper end of the lower frag- 
ment with a small steel instrument, and, as well as I was able, thrust 
it between the fragments. Assisted by Dr. Boardman, I then applied 
a gutta-percha splint from the top of the shoulder to the fingers, 
moulding it carefully to the whole of the back and sides of the limb, 
and securing it firmly with a paste roller. March 4th (not quite four 
weeks after the application of the splint) we opened the dressings for 
the second time, and carefully renewed them. A slight motion was yet 
perceptible between the fragments. March 18th, we opened the dress- 
ings for the third time, and found the union complete. This was 
within less than forty days. The patient was now dismissed. On the 
29th of April following, the bone was.refractured. Mahar had been 
assisting to load the "tender" to a locomotive. As the train was just 
getting in motion, he was hanging to the tender by his sound arm, 
while another laborer seized upon his broken arm to keep himself 
upon the car, and with a violent and sudden pull wrenched him from 
the tender and reproduced the fracture. The next morning I applied 
the dressings as before, and did not remove them during three weeks ; 
at the end of which time the union was again complete. The splint 
was, however, reapplied, and has been continued to this time — a period 
of about six weeks.' m 

Since the date of the above paper, I have twice had opportunities 
to test the value of this mode of treatment in cases of somewhat de- 
layed union of the humerus, and in each case with the same favorable 
result. 

1 Buffalo Med. Journ., vol. x. pp. 14-147. 



242 FEACTUEES OF THE HUMERUS. 



§ 6. Base op the Condyles. (Fractures de V extremite inferieure de 
Vhumerus. — Dupuytren. Fractures sus-condyliennes de Vhumerus. — Mal- 
gaigne.) 

Causes. — Of sixteen fractures at this point, ten occurred in children 
under ten years of age, the youngest being two years old. 

In ten cases, the fracture had been produced by a fall, and it is 
presumed that the blow was received upon the elbow ; in the remain- 
ing six cases the cause is not stated. I believe, therefore, that this 
fracture is generally the result of an indirect blow, inflicted upon the 
extremity of the elbow ; in a few examples, it has been produced by 
a blow received directly upon the point of fracture, as by the kick of 
a horse, &c, but I have never, save in a single instance, been able to 
trace it to a fall upon the hand. 

Fig. 62. 




Fractures at the base of the condyles. (From Gray.) 



Direction of the Fracture, Displacement, and Symptoms. — I think 
this fracture is generally oblique, and its line of direction upwards 
and backwards; in nine of the eleven cases where this point was 
determined, such has been its apparent direction, and the lower frag- 
ment has been found drawn up behind the upper. Once I have found 
the lower fragment in front, and once on the outside of the upper. 

Three of the sixteen were compound, comminuted fractures, this 
being a larger proportion of serious complications than is usually 
found in connection with fractures of long bones. 

I have never met with what I supposed to be a separation of the 
lower epiphysis, but surgical writers have occasionally spoken of this 
accident, and Dr. Watson, of New York, believes that he has seen one 
example in an infant not quite two years old. The limb had been 
violently wrenched by the mother, in attempting to lift her. She was 
not seen by Dr. Watson until the fourth day, at which time the swell- 
ing was such that the diagnosis could not be easily made out; but on 
the ninth day "it was apparent that the shaft of the humerus had been 
separated from its cartilaginous expansion at the condyles, near the 
elbow." By the use of angular pasteboard splints, the reduction was 



BASE OF THE CONDYLES. 



243 



Fig. 



maintained, and the fragments became united after about four or six 
weeks. 1 

Dr. J. C. Eeeve, of Dayton, Ohio, has recently sent me a specimen 
of this fracture which occurred in his practice in the year 1864. A 
girl, set. 10, fell a few feet, striking, probably, upon her 
elbow. The fracture was compound, and union not 
having occurred at the end of three weeks the condition 
of the arm rendered amputation necessary. In this case 
a small fragment of the shaft came away with the epi- 
physis. Drs. Little, Yoss, and Buck, of this city, have 
each reported a similar case. 2 

The diagnosis of this fracture is attended with pecu- 
liar difficulties, and it has occasionally been mistaken 
for a dislocation of the radius and ulna backwards. 
Dupuytren says : " There is nothing so common as to 
see a fracture of the lower end of the humerus, imme- 
diately above the elbow-joint, mistaken for a dislocation 
backward;" and he mentions three cases which have 
come under his own observation. I have found an op- 
posite error, however, by far the most frequent, namely, 
a dislocation of both bones backwards has been sap- 
posed to be a fracture. 

The sources of this embarrassment are found in the 
proximity of the fracture to the joint, in the rapidity 
with which swelling occurs, and in the striking simi- 
larity of the symptoms which characterize the two ac- 
cidents. 

It will be necessary, therefore, to establish with care 
the differential diagnosis. The following are the signs of fracture:— 

1. Preternatural mobility, which, owing to the rapidity of the swell- 
ing and the contraction of the muscles whose tendons are stretched 
over the projecting ends of the bones, is often soon lost, being suc- 
ceeded, sometimes after a few hours, by a rigidity equal to that which 
is usually present in dislocations, or even greater. It is especially 
difficult to flex the arm, owing to the pressure by the upper fragment 
into the bend of the elbow. 

2. Crepitus. This can usually be detected at any period if the arm 
is sufficiently extended, so as to bring the broken surfaces again into 
apposition. 

3. When the extension is sufficient, reduction is easily effected, and 
the natural length of the arm is restored, but the limb immediately 
shortens when the extension is discontinued — especially if at the same 
moment the elbow is bent. This is a very important means of diag- 
nosis. 

4. A careful measurement, made from the point of the internal con- 
dyle to the acromion process, declares a positive shortening of the 
humerus. 



Separation of 
lower epiphysis. 



1 Watson, New York Journ. Med., Nov. 1853. p. 430, second series, vol. xi. 

2 Little, Voss, and Buck, New York Journ. Med., Nov. 1865, p. 133. 



244 FRACTURES OF THE HUMERUS. 

5. By flexing and extending the forearm upon the arm, while the 
fingers are placed upon the lower portion of the humerus, the project- 
ing fragments can be felt. Generally, the upper fragment being in 
front of the lower, and pressing down into the bend of the elbow, its 
end cannot be so easily recognized ; but the upper end of the lower 
fragment can easily be made out when the forearm is considerably 
flexed. The lower end of the upper fragment feels more rough, and 
is less wide, than in dislocations. 

6. The whole of the lower fragment is carried backwards, and with 
it the radius and ulna, producing a striking prominence of the elbow 
and olecranon process. Efforts to straighten the forearm upon the 
arm, when no extension is used, increase rather than diminish this 
projection. 

7. The forearm is slightly flexed upon the arm ; the angle made at 
the elbow being about 25 or 30 deg. 

8. The hand and forearm are pronated. 

9. The relations of the olecranon process with the two condyles re- 
main unchanged. 

Sigiis of a dislocation of the radius and ulna backwards. 

1. Preternatural rigidity. 

2. Absence of crepitus. It is in this joint especially that surgeons 
have been deceived by the chafing of the dislocated bones upon the 
inflamed joint surfaces, and have supposed that they discovered crepi- 
tus when no fracture existed. The rapidity with which inflammation 
develops itself after dislocations of the elbow-joint, and the consequent 
abundant effusion of lymph, afford the probable explanation of this 
frequent error. 

3. When reduced, the bones are not generally disposed to become 
again displaced, even though the elbow should be flexed. 

4. The humerus is not shortened, but the olecranon process ap- 
proaches the acromion process. 

5. There are no sharp projecting points of bone. The lower end 
of the humerus may not always be felt in the bend of the elbow ; but 
when it is felt, it is found to be relatively smooth, broad, and round. 

6. A remarkable prominence of the elbow and olecranon process, 
which prominence is sensibly diminished when an effort is made to 
straighten the forearm on the arm. 

7. Forearm flexed upon the arm to about the same degree as in frac- 
ture. 

8. Hand and forearm pronated, precisely as in fracture. 

9. Eelations of the olecranon process to the condyles changed very 
greatly. 

The most constant diagnostic' signs are, then, in the case of a frac- 
ture — crepitus, shortening of the humerus, projection of the sharp 
ends of the fragments, and an increase of the projection of the elbow 
when an attempt is made to staighten the arm ; and in the case of a 
dislocation, the absence of crepitus, humerus not shortened, while the 
olecranon approaches the acromion process ; the smooth, round head 
of the humerus lost, or indistinctly felt in the bend of the elbow and 



BASE OF THE CONDYLES. 245 

the projection of the point of the elbow diminished when an attempt 
is made to straighten the forearm on the arm. 

It is proper, also, to repeat here what we have already said in rela- 
tion to the causes of this fracture. A fracture at this point is pro- 
duced almost always by a fall upon the elbow, but a dislocation of the 
radius and ulna backwards can never be. On the other hand, a dislo- 
cation is produced in most cases, by a fall upon the palm of the hand, 
while I have never known but one fracture above the condyles to be 
thus produced. 

Results. — Nine times have I found the arm shortened from half an 
inch to one inch, or a little more. 

Muscular anchylosis is almost always present when the apparatus 
is first removed, and it is seldom completely dissipated until after 
several months ; but I have found more or less anchylosis at seven 
and nine months ; and twice after the lapse of three years the motions 
of the joint have been very limited. A few years since, I examined 
the arm of a gentleman who was then twenty-seven years old. and 
who informed me that when he was four years old he broke the 
humerus just above the condyles. There still remained a sensible 
deformity at the point of fracture — he could not completely supine 
the forearm. The whole arm was weak, and the ulnar nerve re- 
markably sensitive. The ulnar side of the forearm, and also the ring 
and little fingers, were numb, and have been in this condition ever 
since the accident. I know the surgeon very well who had charge of 
this case, and I have no doubt that the treatment was carefully and 
skilfully applied. 

In June, of 1850, I operated upon a lad, nine years old, by sawing 
off the projecting end of the upper fragment, whose arm had been 
broken nine months before. This fragment was lying in front of the 
lower, and the skin covering its sharp point was very thin and tender. 
There was no anchylosis at the elbow-joint, but the hand was flexed 
forcibly upon the wrist, the first phalanges of all the fingers ex- 
tended, and the second and third flexed. Supination and pronation 
of the forearm were lost. The forearm and hand were almost com- 
pletely paralyzed, but very painful at times. The ulnar nerve could 
be felt lying across the end of the bone. 

In the hope that some favorable change might result to the hand 
by relieving the pressure upon the nerve, yet with not much expecta- 
tion of success, I exposed the bone and removed the projecting frag- 
ment. The nerve had to be lifted and laid aside. About one year 
from this time I found the arm in the same condition as before the 
operation. 

Non-union is a result not so frequent in fractures at this point as 
higher up ; but Stephen Smith, of the Bellevue Hospital, New York; 
reports a case of non-union in a young man of twenty-three years. He 
was admitted to the hospital on the seventh day after the accident. 
The fracture was simple and transverse, yet at the end of four months 
he was dismissed " with perfectly free motion at the point of fracture." 1 
The failure to unite was attributed to a syphilitic taint. 

1 S. Smith, New York Journal of Medicine, May, 1857, p. 386, third series, vol. ii. 



246 



FRACTURES OF THE HUMERUS 



A case was recently tried in the Supreme Court at Brooklyn, 1ST. Y., 
in which, after a simple fracture at this point, the arm being dressed 
with splints and bandages, the little finger sloughed off in a condition 
of dry gangrene, and the adjacent parts of the hand were attacked 
with humid mortification. Drs. Parker and Prince believed that this 
serious accident was the result of bandages applied too tightly and 
suffered to remain too long, while Drs. Valentine Mott, Eogers, Wood, 
Ayres, Dixon, and others, believed the gangrene might have been 
due to other causes over which the surgeon had no control. 1 

A few years ago, a similar case occurred in the town of Spencer, 
Tioga Co., N. Y. ; a boy, six years old, having broken his humerus 
just above the condyles. The fracture was oblique. The surgeon 
who was called to treat the case was an old and highly respectable 
practitioner. I am not informed of the plan of treatment any farther 
than that a roller was applied. On the eighth day, a second surgeon 
was employed, who, finding the hand cold and insensible, removed all 
of the dressings ; after which the thumb and forefinger sloughed, with 
other portions of the skin and flesh of the hand and arm. The sur- 
geon who was first in attendance was prosecuted, and the case was 
tried in the Supreme Court of that county, but the jury found no 
cause of action. Dr. Hawley, of Ithaca, and the late Dr. Webster, of 
Geneva Medical College, testified that, in their opinion, the death of 
the fingers was owing to the pressure of the fragment upon the bra- 
chial artery, and not to the tightness of the bandages. 

Dr. Gross has also informed us of still another case of the same 
character, which occurred in Warren Co., Ky. A boy, ten years old, 
had broken his arm above the condyles, and his parents having em- 
ployed a surgeon residing at some distance, the dressings were applied, 

and directions given to send for 
Fig. 64. the surgeon whenever it became 

necessary. The parents saw the 
arm swell excessively, and knew 
that the boy was suffering very 
much, but did not notify the 
surgeon until the tenth day, 
when the hand was found to be 
in a condition of mortification, 
and at length amputation became 
necessary. 

Long afterward, in the year 
1851, when the boy became of 
age, he prosecuted his surgeon, 
but with no result to either party beyond the payment of their re- 
spective costs. 

While I would not deny that in all of these cases the sloughing might 
have been solely due to the tightness of the bandages, against which 
cruel and mischievous practice we cannot too loudly declaim, a know- 
ledge of the anatomy of these parts, and the opinions of the very dis- 




Physick's elbow splints. 



New York Medical Gazette, vol. xii. pp. 46, 80, 111. 



BASE OF THE CONDYLES. 



247 



tinguished gentlemen who testified in defence of these surgeons, must 
compel us to admit the possibility of such accidents where the treatment 
has been skilful and faultless. 

Treatment. — The splints generally employed in this country, in frac- 
tures about the elbow-joint, are simple angular side splints, without 
joints, such as those recommended by Physick. 1 

Fig. 65. 




Kirkbride's elbow splint. 



Angular pasteboard splints, felt, leather, gutta percha, &c, or 
angular splints with a hinge, such as Kirkbride's, 2 Thomas Hewson's, 



Fig. 66. 



Fig. 67. 




Rose's splint. 




Welch's splint. The hinges may be transferred to 
splints of different sizes. 



Day's, or Rose's, or the more perfect and elegant angular splint of 
Welch. 

Kirkbride's splint, which has been used in the Pennsylvania Hos- 
pital in several instances, is composed of two pieces of board, connected 
together by a circular joint, and having eyes on the inner edge, two 



1 Elements of Surgery, by John Syng Dorsey, Philadelphia edition, vol. i. p. 145. 

2 American Journal of the Medical Sciences vol. xvi. p. 315. 



248 



FRACTURES OF THE HUMERUS. 



inches apart, and holes through the splint at graduated distances 
between them. There is also a swivel eye, passing through the upper 
part of the splint, and riveted below. A wire is fastened to the swivel, 
and bent at right angles at its other extremity, of a size to fit the eyes 
and holes in the splint. This splint, properly supported by pads, is to 
be placed either upon the outside or inside of the arm, and secured by 
rollers. When the angle is to be changed, the wire is unhooked and 
removed to another eye, or to some of the intermediate holes upon the 
side of the splint. Dr. Kirkbride reports two cases of fracture of the 
lower part of the humerus treated by this plan, one of which resulted 
in anchylosis, but the other was much more successful. 

H. Bond, of Philadelphia, has contrived a very ingenious splint for 
the elbow-joint, and which is designed also to afford a complete sup- 
port to the forearm. 

For myself, I generally prefer gutta percha, moulded and applied 
accurately to the limb, in the same manner as I have already directed 
in fractures of the surgical neck and shaft of the humerus. It should 




Bond's elbow splint. 



be extended beyond the elbow to the wrist, so as to support the whole 
length of the arm, elbow, and forearm. Some- experience in the use 
of wooden angular splints has convinced me that they cannot be very 
well fitted to the many inequalities of the limb; and neither paste- 
board nor binder's board has sufficient firmness, especially in that por- 
tion which covers the joint. Angular splints, furnished with a mova- 
ble joint, possess the advantage of enabling us to change the angle of 
the limb at pleasure, and of keeping up some degree of motion in the 
articulation without disturbing the fracture or removing the dress- 
ings ; but the cross-bars of Day's and Eose's splints render them com- 
plicated, and are in the way of a nice application of the rollers; while 
they are all equally liable to the objection stated against angular 
wooden splints without joints, viz., that they seldom can be made to 
fit accurately the many irregularities of the arm, elbow, and forearm. 
In applying this splint care must be taken that the humeral portion 



BASE OF THE CONDYLES. 



249 



is not too short, or the result will be an unnecessary degree of over- 
lapping of the fragments. This may generally be avoided if the sur- 
geon will first shape his material 
to the sound arm, while the whole 
length is underlaid with three or 
four thicknesses of woollen cloth. 
Welch's splints, made of a mate- 
rial possessing a slight amount of 
flexibility, approach more nearly 
the accomplishment of these indi- 
cations than any other manufac- 
tured splint with which I am 
acquainted, but the number of 
cases in practice to which they 
are applicable will be found to 
be limited, while gutta percha 
has no limit in its application. 

Whatever material is employed, 
the splint should be first lined 
with woollen cloth, or some pro- 
per substitute. A pretty large 
pledget of fine cotton batting 
ought, also, to be laid in front of 
the elbow-joint, to prevent the 
roller from excoriating the deli- 
cate and inflamed skin; and great 
care should be taken to protect the bony eminences about the joint, 
or, rather, to relieve them from pressure, by increasing the thickness 
of the pads above and below these eminences. 

At a very early day, so early, indeed, as the seventh or eighth clay, 
the splint should be removed, and, while the fragments are steadied, 
gentle, passive motion should be inflicted upon the joint. This prac- 
tice should be repeated as often as every second or third day, in order 
to prevent, as far as possible, anchylosis. If much swelling follows 
the injury, it is my custom to open the dressings, without removing 
the splints, on the second or third day after the accident, or at any 
time when the symptoms admonish of its necessity. Occasionally 
it is well to change the angle of the splint before reapplying it. If 
the angular splint with a movable joint is used, slight changes may be 
made while the splint is on the arm ; but if the angle is much changed 
without removing the rollers, they become unequally tightened over 
the arm, and may do mischief. 

When anchylosis has actually taken place, we may, more or less, 
overcome the contraction of the muscles and of the ligaments by pas- 
sive motion, or by directing the patient to swing a dumb-bell or some 
other heavy weight, as first recommended by Hildanus. 




The author's elbow splint. 



17 




250 FRACTURES OF THE HUMERUS. 



§ 7. Fracture at the Base of the Condyles, complicated with Frac- 
ture BETWEEN THE CONDYLES, EXTENDING INTO THE JOINT. 

This fracture, which is but a variety or complication of the preced- 
ing, is even more difficult of diagnosis ; and its signs, results, and 
proper treatment differ sufficiently to demand 
Fi g- 70. a separate consideration. 

I have recognized the accident six times. 
Confined to no period of life, it seems to be the 
result of a severe blow inflicted directly upon 
the lower and back part of the humerus, or 
upon the olecranon process. Dr. Parker, of 
New York, was inclined to regard an obscure 
accident about the elbow-joint, which he saw 
in a lad sixteen years old, as a longitudinal 
fracture of the humerus, with separation of one 
condyle, but which had been occasioned by a 

fall Upon the hand.' For myself, I Should re- 
Fracture at the base of, and g ard this latter circumstance as presumptive 
between the condyles. evidence that it was not a fracture of this cha- 

racter, yet I do not mean to deny the possi- 
bility of its occurrence in this way. 

Its characteristic symptoms are, increased breadth of the lower end 
of the humerus, occasioned by a separation of the condyles ; displace- 
ment upwards and backwards of the radius and ulna ; crepitus and 
mobility at the base of the condyles, with crepitus also between the 
condyles, developed by pressing them together ; or when the radius 
and ulna are drawn up, by restoring these bones first to place by 
extension, and then pressing upon the opposite condyles ; shortening 
of the humerus. 

Its consequences are, generally, great inflammation about the joint, 
permanent deformity and bony anchylosis. An opposite result must 
be regarded as fortunate, and as an exception to the rule. 

Of the treatment, we can only say that it must be chiefly directed 
to the prevention and reduction of inflammation, at least during the 
first few days. Nor is this inconsistent with an early reduction of the 
fragments, and moderate efforts, by splints and bandages, such as we 
have directed in case of a simple fracture at the base of the condyles, 
to keep the fragments in place. No surgeon would be justified in 
refusing altogether to make suitable attempts to accomplish these im- 
portant indications; but he must always regard them as secondary 
when compared with the importance of controlling the inflammation. 

When splints are emploj^ed, the same rules will be applicable both 
as to their form and mode of application, as in cases of simple fracture 
above the condyles. 

The following examples will more completely illustrate the charac- 
ter, history, and proper treatment of these cases than any remarks or 
rules which we can at present make. 

1 Paiker, New York Journal of Medicine, Nov. 1856, p. 391, 3d series, vol. i. 



FKACTUEE AT THE BASE OF THE CONDYLES. 251 

A woman, set. 4A, fell upon the side-walk in January, 1850, striking 
upon her right elbow. I saw her a few minutes after the accident, 
but the parts about the joint were already considerably swollen, and 
it was not without difficulty that the diagnosis was made out. The 
forearm was slightly flexed upon the arm, and pronated. On seizing 
the elbow firmly, a distinct motion was perceived above the condyles, 
and a crepitus. I could also feel, indistinctly, the point of the upper 
fragment. While moderate extension was made upon the arm, the 
condyles were pressed together, when it was apparent that they had 
been separated. On removing the extension, they again separated, 
and the olecranon drew up. She was in a condition of extreme ex- 
haustion, and the bones were easily placed in position. 

An angular splint was secured to the limb, and every care used to 
support the fragments completely, but gently. 

From this date until the conclusion of the treatment the dressings 
were removed often, and the elbow moved as much as it was possible 
to move it. 

Seven months after the accident, the elbow was almost completely 
anchylosed at a right angle. The fingers and wrist also were quite 
rigid. Six years later, the anchylosis had nearly disappeared ; she 
could now flex and extend the arm almost as much as the other ; the 
wrist-joint was free, and the fingers could be flexed, but not sufficiently 
to touch the palm of the hand. The line of fracture through the base 
could be traced easily, but the humerus was not shortened. There 
was, moreover, much tenderness over the point of fracture through the 
base, and at other points. Occasionally, a slight grating was noticed 
in the radio-humeral articulation. She experienced frequent pains in. 
the arm, and especially along the back and radial border of the ring 
finger. During the first year or two after the accident, the arm per- 
ished very much, but although the hand remained weak, the muscles 
were now well developed. 

A gentleman was struck with the tongue of a carriage with which 
a couple of horses were running. The blow was received directly 
upon the back of the left elbow. Dr. Sprague and myself removed 
some small fragments of bone, and while opening the wound for this 
purpose, we could see distinctly the line of fracture extending into the 
joint as well as across the bone. The condyles were not separated. 

The subsequent treatment consisted only in the use of such means 
as would best support the limb, and most successfully combat inflam- 
mation. The arm and forearm were laid upon a broad and well 
cushioned angular splint, covered with oil-cloth, to which they were 
fastened by a few light turns of a roller. 

Twelve years after, I found the humerus shortened one inch and a 
half. During the first year, he says, there was no motion in the elbow- 
joint, but he can now flex and extend the forearm through about 45° ; 
when flexed to a right angle, it seems to strike a solid body like bone. 
Rotation of the forearm is completely lost, the hand being in a posi- 
tion midway between supination and pronation. He suffers no pain, 
and his arm is quite strong and useful. No means have been em- 



252 FRACTURES OF THE HUMERUS. 

ployed to restore the functions of the limb but passive motion at first, 
and subsequently constant, active use of the hand and arm. 

The late Dr. Thomas Spencer, of Geneva, used to relate a case in 
which a surgeon was called to what he supposed to be a fracture of the 
lower end of the humerus, and which he treated accordingly, with 
splints, &c. On the second or third day, another surgeon was called, 
who removed the splints and bandages, and pronounced it a disloca- 
tion of the radius and ulna backward ; but he was unable to reduce it. 

After some time, the first surgeon was prosecuted for having treated 
as a fracture what proved to be a dislocation. Dr. Spencer, who had 
examined the arm carefully, gave his testimony last, and at a time 
when, from the evidence, it seemed almost certain that the surgeon 
must be mulcted in heavy damages ; but he declared his belief that 
both surgeons were right, since, on measuring the breadth of the 
humerus through its two condyles, he found that the' humerus of the 
injured arm was three-quarters of an inch wider than the opposite. 
His conclusion, therefore, was that the condyles had been split asunder 
and were now separated ; that the first surgeon properly reduced this 
fracture, but that when, on the second or third day, the second sur- 
geon removed the splints and the dressings, a contraction of the mus- 
cles had taken place and the dislocation occurred, the bones of the 
forearm being drawn up between the fragments. Dr. Spencer believed 
this was an example of the variety of fracture now under considera- 
tion, but it is not quite certain that there was anything more than an 
oblique fracture extending into the joint, followed by a dislocation. 
In either case, the first surgeon was entitled to an acquittal, and so the 
jury promptly declared by their verdict. 

In a case of compound comminuted fracture of the character now 
under consideration, Dr. Stone, of the Bellevue Hospital, New York, 
removed the condyles and sawed off the sharp end of the humerus. 
The woman was twenty-six years old and intemperate. The operation 
was made as a substitute for amputation. No serious complications 
followed. On the ninety-sixth day, the wounds were completely healed, 
and she could bend the forearm to a right angle with the arm, the 
action of the muscles having drawn up the radius and ulna against 
the lower end of the shaft of the humerus, so that the motions were 
natural and free. 1 The practice, as the result sufficiently shows, was 
eminently judicious ; and its practicability ought always to be well 
considered before resorting to the serious mutilation of amputation. 
The great principle upon which the success of resection is here based 
is the shortening of the bone, whereby the reduction may be accom- 
plished without painful tension to the muscles ; a principle which will 
demand of us hereafter a more careful consideration and a wider 
application. 

Fractures of the Condyles. 

Chaussier described that portion of the lower end of the humerus 
which articulates with the ulna as the trochlea, and that portion which 

1 Stone, New York Journ. of Med., May, 1851, p. 302, vol. vi. 2d series. 



FRACTUKES OF THE INTERNAL EPICONDYLE. 



253 



articulates with the radius as the condyle ; naming the two lateral pro- 
jections, respectively, epitrochlea and epicondyle. Some of the French 
writers have adopted this nomenclature, but I prefer, as being more 
familiar to my own countrymen, the terms external and internal con- 
dyle, to which it will be convenient to add the terms external epicon- 
dyle and internal epicondyle, as indicating the extreme lateral projec- 
tions, which are formed from separate points of ossification, and which 
do not become united to the condyles by bone until about the sixteenth 
or eighteenth years of life. 

When, therefore, we speak of a fracture of the epicondyle, we refer 
only to a separation of the epiphysis, such as it is in early life ; or to 
its true fracture, when, at a later period, it has become united by bone. 



§ 8. Fractures Of the Internal Epicondyle. (Epitrochlea Chaussier.) 



This is the fracture which Granger first described in the Edinburgh 
Medical and Surgical Journal, 1 and which he ascribed solely to muscu- 
lar action. " A distinguishing circumstance attending this fracture is 
that of its being occasioned by sudden and violent 
muscular exertion ; and it will be recollected that 
from the inner condyle those powerful muscles 
which constitute the bulk of the fleshy substance 
of the ulnar aspect of the forearm have their 
principal origin. The way in which the muscles 
of the inner condyle are involuntarily thrown 
into such sudden and excessive action I take to 
be this : the endeavor to prevent a fall by stretch- 
ing out the arm, and thus receiving the per- 
cussion from the weight of the body on the 
hand." 2 

It is a fact, perhaps of some significance in 
this connection, that most of these fractures 
occur in children, before the union of the epi- 
physis is completed, when muscular contraction 
might more often prove adequate to its separa- 
tion, and when the epicondyle is less prominent, 
and, therefore, less exposed to direct blows than in adult life; thus, of 
five fractures which I have distinctly recognized as fractures of the 
epicondyle, all, except one, occurred between the ages of two and 
fifteen years. But then it is equally true that a large majority of all 
the fractures of the internal condyle, including those which enter 
the articulation, as well as those which do not, belong to childhood 
and youth. I have seen but two exceptions in fifteen cases. Since, 
then, direct blows generally produce those fractures which penetrate 
the joint, no good reason can be shown why they should not produce 
fractures of the epicondyle. One of the exceptions to which I have 




Fracture of internal epicon- 
dyle. 



1 "Ona Particular Fracture of the Inner Condyle of the Humerus," by Benjamin 
Granger, Surgeon, Burtou-upon- Trent. Op. cit., vol. xiv. pp. 19o-20l, April, 1818. 

2 Ibid., p. 196. 



254 FRACTUKES OF THE HUMERUS. 

referred as not having occurred in early life, is sufficiently rare to en- 
title it to especial notice. 

On the 16th of May ; 1856, a laborer, thirty-four years of age, fell 
from an awning upon the side-walk, dislocating the radius and ulna 
backwards ; the dislocation was immediately reduced by a woman who 
came to his assistance, but when he called on me, soon after, I found 
a small fragment of the inner condyle, probably the epi condyle alone, 
broken off and quite movable under the finger. It was slightly dis- 
placed in the direction of the hand. 

I could not learn positively whether in falling he struck the elbow 
or the hand, but there was presumptive evidence that he struck the 
hand ; if so, then probably the fracture was the result of muscular 
action, which is the more extraordinary as having taken place in a 
man of his age. 

It is pretty certain, however, that the theory of causation adopted 
by Granger is too exclusive. A lad was brought to me in October, 
1848, aged eleven, who had just fallen upon his elbow, the blow having 
been received, as he affirmed, and as the ecchymosis showed pretty 
conclusively, directly upon the inner condyle. The fragment was 
quite loose, and crepitus was distinct. He could flex and extend the 
arm, and rotate the forearm, without pain or inconvenience. I am 
quite sure the fracture did not extend into the joint; the result seemed 
also to confirm this opinion, for in three months from the time of the 
accident the motions of the elbow-joint were almost completely re- 
stored. 

Indeed, Mr. Granger has failed to establish, by any particular proofs, 
that in more than one or two of his cases the fracture was the result 
of muscular action ; but, on the contrary, I am disposed to infer, from 
the violent inflammation which generally ensued in his cases, from 
the frequency of ecchymosis, and especially from the inj ury done to 
the ulnar nerve in at least three instances, that most of them were 
produced by direct blows inflicted from below in the fall upon the 
ground. Fractures produced by muscular action are seldom accom- 
panied with much inflammation or effusion of blood, and it is much 
more probable that the ulnar nerve should have been maimed by the 
direct blow which caused the fracture, than by the displacement of the 
epiphysis, which is, as we shall presently show, almost always carried 
downwards, and oftener slightly forwards than backwards. It is only 
when the fragment is forced directly backwards that the ulnar nerve 
could be made to suffer ; a direction which, it does not seem to me, it 
could ever take from muscular action alone. 

Direction of Displacement, Symptoms, &c. — I have seen this fragment 
displaced in the direction of the hand, or downwards, very manifestly, 
twice, and in two other examples a careful measurement showed a 
slight displacement in the same direction. The greatest displacement 
occurred in a boy fifteen years old, who was brought to me from St. 
Catharine's, Canada West. He had fallen upon his arm in wrestling, 
and his surgeon found a dislocation of the bones of the elbow-joint, 
which he immediately reduced. The fracture was not at that time 
detected, the arm being greatly swollen. No splints were applied. It 



FRACTURES OF THE INTERNAL EPICONDYLE. 255 

was three months after the accident when I saw him, at which time I 
found the internal epicondyle broken off and removed downwards 
toward the hand one inch and a quarter; and at this point it had 
become immovably fixed. Partial anchylosis existed at the elbow- 
joint, but pronation and supination were perfect. 

In one instance I believed the fragment to be carried about three 
lines upwards and two backwards toward the olecranon ; in each of 
the other examples the fragment has not seemed to suffer any sensible 
displacement. 

Granger found, also, in the five examples which came under his 
notice, the epicondyle carried toward the hand, with, more or less 
variation in its lateral position, so that while in some instances it 
touched the olecranon, in others it was removed an inch or more in 
the opposite direction. 

It is probable that, except where controlled by the force and direc- 
tion of the blow, or by some complications in the accident, the frag- 
ment, if displaced at all, always moves downwards towards the hand, 
or downwards and a little forwards, in the direction of the action of 
the principal muscles which arise from this epiphysis ; and when the 
fracture or separation is the result of muscular action alone, this form 
of displacement seems to me to be inevitable. In addition to the 
mobility, crepitus, and generally slight displacement of the fragment, 
which are the principal signs of this fracture, it may be noticed that 
there is usually some embarrassment in the motions of the elbow-joint, 
which may be due in part to the swelling, and in part to the detach- 
ment of the point of bone from and around which most of the pro- 
nators and flexors of the forearm have their rise. In one instance, 
already quoted, that of the lad aged eleven years, who broke the 
epicondyle from a direct blow, the motions of pronation, with flexion, 
were not at all impaired, neither immediately nor at any subsequent 
period, but the fragment was never sensibly, or only very slightly 
displaced. 

Granger has recorded another class of symptoms, to which I have 
already alluded, his explanation of which, however, I am not prepared 
to admit. One of these cases he describes as follows : A boy, eight 
years old, fell with violence, and broke off completely the whole of 
the inner epicondyle of the right humerus. The lad said he had 
fallen on his hand. The fragment was displaced toward the hand. 
Severe inflammation followed, but he recovered the free and entire 
use of the elbow-joint in less than three months after the accident. 
No splints or bandages were ever employed. 

From the moment of the accident, the little finger, the inner side of 
the ring finger, and the skin on the ulnar side of the hand, lost all 
sensation. The abductor minimi digiti and two contiguous muscles 
of the little finger were also paralyzed. This condition lasted eight or 
ten years, after which sensation and motion were gradually restored 
to these parts. As a consequence of this paralyzed condition of the 
ulnar nerve, also, successive crops of vesications, about the size of a 
split horse-bean, commenced to form on the little finger and ulnar 
edge of the hand some weeks after the accident, leaving troublesome 



256 FRACTURES OF THE HUMERUS. 

excoriations. This eruption did not entirely cease for two or three 
months. 

In two other cases, Mr. Granger remarks that he has found " the 
same paralysis of the small muscles of the little finger, the same loss 
of feeling in the integuments, and the same succession of crops of 
vesicles on the affected parts of the hand, as is described to have 
occurred in the preceding case." 

Without intending to intimate a doubt of the accuracy of Mr. Gran- 
ger's statement, that such phenomena have followed in three cases out 
of the five which he has seen, I must express my belief that it was 
only a remarkable concurrence of circumstances, since the same phe- 
nomena have never been seen by myself, nor do I know that they 
have been observed by any other surgeon. 

Results. — As in all other accidents about the elbow-joint, a tem- 
porary rigidity is almost inevitable. The mere confinement of the 
arm in a flexed position is sufficient to determine this result without 
the interposition of a fracture ; but when inflammation occurs, more or 
less contraction of the tendons, muscles, &c, about the joint must en- 
sue. To this circumstance, therefore, added to the confinement, rather 
than to the fracture, will be due the anchylosis. If the fragment is 
not displaced, the fracture cannot certainly be responsible for the loss 
of motion, since it does not in any way involve the joint ; and if dis- 
placement exists, its ultimate effect in diminishing the power of the 
muscles which arise from the epiphysis must be only trivial and 
scarcely appreciable. We might, therefore, reasonably conclude that 
where the accident has been properly treated, permanent anchylosis 
would be the exception and not the rule. This view of the matter 
seems also to be sustained by the recorded results. In Granger's cases, 
the full range of flexion and extension of the forearm has been finally 
restored, or with so trifling an exception as not to be observable with- 
out close attention, in every instance; except in the one already 
mentioned, which was originally complicated with dislocation ; and 
even in this case the ultimate maiming was inconsiderable. Malgaigne, 
who says " it ought to be understood that in this accident articular 
rigidity is almost inevitable," seems nevertheless to admit the justness 
of Granger's observations as to the final result, if the proper means 
are employed to prevent it. I have myself found only once any con- 
siderable impairment of the motions of the joint after the lapse of a 
few years. 

Treatment — This accident does not constitute an exception to the 
rule which experience has established, that epiphyseal projections 
when once displaced can seldom be restored completely to position or 
maintained in position, until a bony union is consummated. Granger 
remarks : " I have purposely avoided saying one word about replacing 
the detached condyle (epicondyle), and for these reasons : during the 
state of tumefaction of the limb, no means could be adopted for con- 
fining the retracted condyle in its place, beyond that of the relaxation 
of the muscles; and both before the tumefaction has commenced, and 
after it has subsided, all endeavors to replace the condyle, or even to 
change the position of it, have failed." He even proceeds so far as to 



FRACTURES OF THE EXTERNAL EPICONDYLE. 



257 



declare that, while attention ought to be given to the reduction of the 
inflammation by appropriate means, we ought, nevertheless, to instruct 
the patient to flex and extend the arm daily from the moment the ac- 
cident occurs until the cure is completed, and without any regard to 
the consolidation of the fragment; "the exercise of the joint in this 
manner must constitute the principal occupation of the patient for 
several weeks ; and should it be remitted during the formation and 
consolidation of the callus, much of the benefit which may have been 
derived from this practice will be lost, and will wifeh difficulty be re- 
gained." 

With only slight qualifications I would adopt the advice of Mr. 
Granger. The limb ought, at first, to be placed in a position of semi- 
flexion, so that if anchylosis should unfortunately ensue, it should be 
in the condition which would render it most serviceable, and also 
because in this position the muscles which tend to displace the frag- 
ment would be most completely relaxed. While thus placed an 
attempt ought to be made, by seizing the epiphysis, to restore it to 
position ; and if the effort succeeds, as it certainly is not very likely to 
do, a compress and roller ought to be so applied as to maintain it in 
position ; provided, always, that it shall not be found necessary to ap- 
ply the roller so tight as to endanger the limb, or increase the inflam- 
mation. An angular splint would be an almost indispensable part of 
the apparel, at least with children, where this indication is in view. 
In no case, however, ought more than seven or fourteen days to elapse 
before all bandaging and splinting should be abandoned, and careful, 
but frequent flexion and extension be substituted. 

In three cases seen by me, a displacement of the fragment, either 
forwards or backwards, has occurred whenever the arm was flexed, 
and it has been necessary, therefore, to treat the case with the arm in 
a straight position. These are plainly only exceptions to the rule. 



§ 9. Fractures of the External Epicondyle. (E pi condyle, Chaussier.) 



I have only mentioned this supposed fracture, 
of which some writers have spoken as a fact, in 
order that I may declare my conviction that its 
existence has never been made out. If we admit 
the possibility, that, while in a state of epiphysis, 
it might, like the corresponding internal epi- 
physis, be separated by muscular action, we 
must yet deny its probability, since it is so ex- 
ceedingly small ; and we must, for the same 
reason, be permitted to doubt whether the fact 
of its separation could be recognized in the 
living subject. Moreover, if a true fracture 
occurs at this point as the result of external 
violence, it is sufficiently plain, from an exami- 
nation of the anatomical structure, that it must 
more or less extend into the joint and involve 
the condyle itself. 



Fig. 72. 




ore of external epicon- 




258 FRACTURES OF THE HUMERUS. 

§ 10. Fractures of the Internal Condyle. {Trochlea, Chaussier.) 

B. Cooper, South, Sir Astley Cooper, and others, speak of fracture 
of the internal cond}<le as very common, and more so than fracture 
of the external condyle; while Malgaigne, who 
Fig. "/3. admits its existence, has never met with a single 

living example, and regards its occurrence as 
exceedingly rare. In a record of fifteen frac- 
tures, I have found no difficulty in recognizing 
five as fractures of the inner condyle; five, I 
have already said, were fractures of the epicon- 
dyle, and the remainder were undetermined, 
while my records furnish eighteen examples of 
undoubted fractures of the external condyle. It 
is probable that Sir Astley did not intend to 
make any ^distinction between fractures of the 
condyle and epicondyle, and this might explain 
somewhat his opinion of the relative frequency 
of these accidents; but even rejecting this im- 
portant distinction, it has happened to me to see 

Fracture of internal con- r , „ ' n -\ ^ ^ 

d y ie. more examples or fracture of the outer condyle 

than of the inner. 

Causes. — It has already been stated that fractures of the internal 
condyle, as well as fractures of the epicondyle, belong almost exclu- 
sively to infancy and childhood, only two instances having come under 
my notice after the eighteenth year of life. 

I have seen no instance which could be traced to any other cause 
than a direct blow, such as a fall upon the elbow, the force of the con- 
cussion being received directly upon the condyle. 

Line of Fracture, Displacement, Symptoms. — The direction of the 
line of fracture is tolerably uniform, namely, commencing about one- 
quarter or half an inch above the epicondyle, it extends obliquely 
outwards through the olecranon and coronoid fossae, and enters the 
joint through the centre of the trochlea. 

Displacement of the lower fragment can take place only in a direc- 
tion upwards, backwards, forwards, and inwards (to the ulnar side). 
The fragment cannot be carried downwards, in the direction of the 
hand, nor outwards, in the direction of the radius, unless the radius 
also is broken or dislocated. 

The most common form of displacement is upwards and backwards, 
and perhaps at the same time a little inwards; the ulna remaining 
attached to the lower fragment, and following its movements. I have 
seen one instance in which the fragment was carried directly down- 
wards toward the hand, but this accident was originally complicated 
with a dislocation of the radius backwards. The dislocation was im- 
mediately reduced. Five years after, when the young man was 
twenty-three years old, I found the condyle displaced downwards 
and forwards about half an inch, so that when the forearm was ex- 
tended it became strikingly deflected to the radial side. 



FRACTURES OF THE INTERNAL CONDYLE. 259 

The symptoms which characterize this fracture are crepitus, almost 
always easily detected; mobility of the fragment, discovered espe- 
cially by seizing upon the epicondyle, or by flexing and extending 
the arm; displacement of the smaller fragment and a projection of the 
olecranon process, this latter being very marked when the forearm is 
extended upon the arm, but almost completely disappearing when the 
elbow is bent ; projection of the lower end of the humerus in front 
when the arm is extended ; the humerus shortened when measured 
along its ulnar side, from the internal epicondyle ; the breadth of the 
humerus, though its condyles generally increased slightly, sometimes 
Lalf an inch or more; if the lesser fragment is carried upwards, it will 
also be found that when the limb is extended, the forearm will be 
deflected to the ulnar side. 

Sir Astley Cooper remarks that it is frequently mistaken for a dis- 
location ; and Thomas M. Markoe, of New York, has shown that it is, 
in fact, frequently complicated with a dislocation of the head of the 
radius backwards ; indeed, he expresses a belief that this dislocation 
of the radius seldom or never occurs without a fracture of the internal 
condyle. 1 I shall refer to his views again when considering disloca- 
tions of the head of the radius. 

Results. — It is probable that in a majority of cases no permanent 
displacement exists; although the irregularity of the bony deposits 
around the base of the condyle, which generally may be easily felt, 
would lead to a contrary opinion. The fact that the lower fragment 
usually follows the motions of the olecranon, renders its replacement 
and retention comparatively easy, unless some complication exists. 
It is not from displacement, therefore, so much as from permanent 
muscular, and especially bony anchylosis, that serious maimings so 
often result. Under any treatment bony anchylosis will very often 
ensue, and under improper treatment it is almost inevitable. 

Treatment. — The arm must be immediately flexed to nearly or quite 
a right angle, when, without much manipulation, the fragments will 
be made to resume their place. A gutta-percha, or felt, right-angled 
splint, such as I have already directed for fractures occurring just 
above the condyles, well and carefully cushioned, may now be applied, 
and secured by rollers. Suitable pads must also aid the splint and 
roller, in keeping the fragments in place. Markoe prefers keeping 
the forearm in a position about ten degrees short of a right angle, be- 
lieving that in this position the ulna itself will act as a splint, and by 
its support on the uninjured portion of the trochlea, hold in its place 
the broken condyle. Yerv properly, also, he prefers to lay the angular 
splint, made of tin, and fitted to the arm and forearm, upon the back 
of the limb instead of upon the front or sides. If it is upon the inside, 
it covers the broken condyle, and we are unable to know so well its 
position; if upon either side, it is apt to press injuriously upon the 
epicondyles ; and if it is in front, the fragments cannot be so well ad- 
justed or supported. Upon this point, however, surgeons are not very 

1 Markoe, New York Journal of Medicine, May, 1855, p. 382, seoond series, vol. xiv. 



260 FRACTURES OF THE HUMERUS. 

well agreed, and no doubt more will depend upon the care with which 
the splint is applied than upon the surface against which it is laid. 

Considerable swelling is almost certain to follow, and no surgeon 
ought to hazard the chances of vesications, ulcerations, &c, by neglect- 
ing to open or completely remove the dressings every day. Within 
seven days, and perhaps earlier, passive motion must be commenced, 
and perseveringly employed from day to day until the cure is accom- 
plished ; indeed, in a majority of cases it is better not to resume the 
use of splints after this period : for, although at this time no bony 
union has taken place, yet the effusions have somewhat steadied the 
fragments, and the danger of displacement is lessened, while the pre- 
vention of anchylosis demands very early and continued motion. 

When the fracture is compound, or otherwise complicated, these 
simple rules will seldom be found applicable ; indeed, fractures attended 
with no such complications will occasionally be found difficult to re- 
duce, or to maintain in position after reduction. 



§ 11. Fractures of the External Condyle. 

Causes. — All the fractures (18) of the external condyle which I have 
seen, occurred in children under fourteen years of age, except one ; in 
which instance a woman, eighty-eight years of age, fell upon her elbow 
while intoxicated, breaking off the outer condyle. Two months after 
the accident I found the fragment displaced half ari inch upwards, and 
firmly united. 

In a large majority of these cases the patients themselves have 
affirmed, and the surface of the skin has furnished conclusive evidence, 
that the fracture was produced by a direct blow, generally by a fall 
upon the elbow. 

Line of Fracture, Displacement, and Symptoms. — The direction of the 
fracture is generally such that, commencing always above and without 
the capsule, it descends obliquely and enters the joint either just within 
or through the "small head" or articulating surface upon which the 
radius is received ; or else it penetrates more deeply in its progress, 
and passing through the olecranon fossa, it enters the joint through 
the middle of the trochlea. 

In the first of these classes of examples, which I think also is the 
most common, the condyle alone is broken off, and it is liable only to 
become displaced backwards, forwards, or outwards ; generally, I have 
found it displaced a little outwards, sufficiently to increase manifestly 
the breadth of the condyles ; or it has been carried backwards ; once 
slightly forwards ; it is also, in some cases, carried upwards in a small 
degree, although the action of the supinators and extensors would seem 
to render a downward displacement more common. These displace- 
ments are usually not considerable, and in a few cases there is none at 
all. Whatever may be the direction or degree in which the fragment 
is moved, however, the head of the radius is found almost always to 
accompany it; but in the case which I am about to relate, the head 
of the radius became completely separated from the condyle. 




FRACTURES OF THE EXTERNAL CONDYLE. 261 

Frederick KeafTer, set. 11, fell from a load of hay, and he is confident 
that he struck the ground with the back of his elbow. Six hours 
after the accident, he was brought to me by the 
physician who was first called to him. The arm Fl S- 74, 

was much swollen, and the external condyle could 
not be distinctly felt, but when pressure was made 
directly upon it, crepitus and motion became mani- 
fest. The head of the radius was at the same time 
dislocated backwards, and separated entirely from 
the condyle ; its smooth button-like head being 
very prominent. It is difficult to conceive how 
a blow from behind should leave the head of the 
radius dislocated backwards, or how the radius 
could have separated from the broken condyle ; 
but as the examination was repeated several 
times, and while the patient was under the influ- 
ence of ether, I have no doubt of the fact. Several 
other surgeons who were present concurred with Fracture of the external 

P . p -., l condyle. 

me in opinion fully. 

While prosecuting the examination, I reduced the dislocation of the 
radius, but it would not remain in place a moment when pressure or 
support was removed. The lad recovered with a very useful arm, the 
motions of flexion and extension, with pronation and supination, after 
the lapse of a year, being nearly as complete as before the accident ; 
the radius remaining unreduced. 

Sometimes it will be noticed that while the portion of the condyle 
which is attached to the radius falls backwards, its upper and broken 
extremity pitches forwards ; and this attitude it is especially prone to 
assume when the forearm is extended. 

It is even possible, when the fracture traverses the trochlea, for the 
ulna also to become displaced backwards along with the radius and 
the lesser fragment. 

Crepitus, which is usually very distinct, is most easily obtained by 
rotating the radius, or by seizing upon the condyle with the thumb 
and fingers, and moving it backwards and forwards. 

Results. — Ordinarily, this fragment unites promptly, and by the 
interposition of a bony callus; but in four cases, I have noticed that 
either no union has occurred, or the union has been accomplished 
only through the medium of fibrous structure, and the fragment con- 
tiuued afterward to move with the radius. 

As a consequence, probably, of the displacement of the lesser frag- 
ment upwards, the forearm, when straightened, is occasionally found 
deflected to the radial side. The surgeon must not, however, confound 
the deflection which is natural, and which is greater in some persons 
than in others, with the unnatural radial inclination which is occa- 
sioned sometimes by this accident. I have met with this phenomenon 
three times in children under three years of age, in one of which I 
could not discover that the condyle was carried toward the shoulder, 
but only outwards ; in each of the other cases the fragment had united 
by ligament. The following is one of the examples referred to: — 



262 FRACTURES OF THE HUMERUS. 

A girl, aet. 3, fell and broke the external condyle of the left humerus ; 
the fracture extending freely into the joint ; crepitus distinct ; forearm 
slightly flexed ; prone. Lesser fragment displaced outwards and a little 
backwards, carrying with it the radius. On the second day I was dis- 
missed on account of the unfavorable prognosis which I gave, or rather 
because I refused to guarantee a perfect limb, and an empiric was 
employed. 

July 2, 1857, several months after the accident, the father brought 
her to me for examination. There was no anchylosis, but the lesser 
fragment had never united, unless by ligament, moving freely with 
the head of the radius. When the forearm was straightened upon 
the arm it fell strongly to the radial side, but resumed its natural 
relation again when the elbow was flexed. 

Two other examples are reported at length in the second part of 
my Report on Deformities after Fractures as Cases 57 and 59 of frac- 
tures of the humerus. 

In one other example, however, mentioned also in my report as 
Case 56, the deflection was to the opposite side. I examined the lad 
one year after the accident, he being then five years old, and I found 
the external condyle very prominent and firmly united, but not appa- 
rently displaced in any direction except outwards. The radius and 
ulna had evidently suffered a diastasis at their upper ends, but all of 
the motions of the joint were free and perfect. 

Dorsey 1 speaks of this lateral inclination as being always to the 
ulnar side, but does not indicate to what particular fracture of the 
elbow it belongs. He has also described a splint, contrived by Dr. 
Physick, intended to remedy the deformity in question. 

Chelius also speaks of the same deformity as occurring after frac- 
tures of the internal, but does not mention it in connection with frac- 
tures of the external condyle, that is, an inclination of the forearm to 
the ulnar side. 

In more than half of the cases of fracture of this condyle some 
degree of anchylosis has resulted, lasting at least several months. I 
have seen it remaining after a lapse of from one to twenty years, but 
generally it gradually diminishes, and, in a majority of cases, com- 
pletely disappears after a few years. 

Treatment. — I do not know that I need add much to what has 
already been said in relation to the treatment of fractures of the 
opposite condyle, and at the base of the condyles, since the measures 
applicable to the one are, in general, applicable to the other. 

Generally, the forearm ought to be flexed upon the arm, especially 
with a view to overcome the usual tendency in the upper end of the 
lower fragment to pitch forwards, and which form of displacement is 
greatly increased by straightening the arm. A remarkable exception 
to this rule, and one of two which I have seen, must be mentioned. 

James Cronyn, aged six, was brought to me in March, 1857, having, 
a few minutes before, fallen from a height of four or five feet to the 
ground. His father said the elbow had been broken at the same point 

1 Elements of Surgery, by Philip Syng Dorsey, Phila. ed., 1813, vol. i. p. 146. 



FEACTUEES OF THE EXTERNAL CONDYLE. 263 

two vears before, and from that time had remained stiff and crooked. 
I found the external condyle broken off, and, with the head of the 
radius, carried backwards. This was the position which it occupied 
constantly, though it was easily restored and maintained in position 
when the arm was straight, but not by any possible means when the 
elbow was flexed. I dressed the arm, therefore, in an extended posi- 
tion, with a long felt splint, and the fragments remained well in place 
until a cure was accomplished. 

In certain examples, I have no doubt also that advantage might be 
derived from the use of Physick's splint, intended to obviate the out- 
ward or inward inclination of the forearm. 

It is especially deserving of notice that, in the four cases in which 
I have observed bony union to fail, and the fragments to continue 
movable, the motions of the elbow-joint have, in a very short time, 
been completely restored. If it does not prove that Granger was 
correct in his views as applied to fractures of the internal epicondyle, 
namely, that it was of little or no consequence whether the fragment 
united or not, and that the elbow-joint ought to be submitted to free 
motion from the beginning to the end of the treatment — if it does not 
absolutely prove, I say, the correctness of his views, it at least must 
abate our apprehensions of the supposed evil results of non-union in 
the case of the fracture now under consideration. 

I shall take the liberty of quoting also, with a qualified approval, 
the opinion of Dr. John C. Warren, of Boston, as stated by Dr. Norris 
in his Report on Surgery, made to the American Medical Association 
in 1848. 

" In the treatment of fractures of the condyles of the os humeri, a 
course is usually recommended which he believes to be hurtful, inas- 
much as it favors the worst consequences of the injury, namely, loss 
of motion in the joint. By this mode of treatment, the fractured piece 
becomes sufficiently fixed to create partial anchylosis ; and there is so 
much pain afterwards in the proposed passive movements as to cause 
the omission of these measures until permanent stiffness takes place. 
The proper course in the management of these accidents, he conceives 
to be, 1st. To apply no splints, but in the earlier days to make use of 
the proper means to prevent inflammation. 2d. To accustom the 
patient to early and daily movements of flexion and extension. 3d. 
When the action of the joint becomes limited, to overcome the resist- 
ance by force, and repeat it daily, until the tendency of the joint to 
stiffen ceases. 

" The accomplishment of this process, he adds, is so very painful 
that few patients have courage to submit to it, and few surgeons firm- 
ness to prosecute it. The consequence has been that in a great num- 
ber of cases the use of the articulation to a greater or less extent has 
been lost. The introduction of etherization, by preventing the pain, 
gives us, in the opinon of Dr. Warren, the means of overcoming the 
resistance. By its aid he has restored the motion of a considerable 
number of anchylosed elbows, and has successfully applied the same 
measures to other joints, particularly to the shoulder and knee. This 
has now become his settled practice, with the results of which he is 



264 FRACTURES OF THE RADIUS. 

entirely satisfied. The inflammation consequent upon the forced 
movements of an anchylosed joint is not to be lost sight of. By a 
reasonable abstraction of blood, and other anti-inflammatory treatment, 
he has never found it alarming." 1 

My respect for the distinguished surgeon whose opinion is here 
given does not permit me to question the correctness of his practice ; 
but I cannot avoid a belief that his language does not convey a precise 
idea of his views. If he intends to say that he would move the joint 
freely when it is suffering from acute inflammation, and when motion 
occasions great pain, I must protest against the practice as likely to 
do vastly more harm than good in any case; but if he would move the 
joint from the first, when the inflammation and swelling are trivial, 
and when it occasions only an endurable amount of pain, then his 
views are just and his practice worthy of imitation. 



CHAPTER XXI. 

FRACTURES OF THE RADIUS. 

Of eighty-six fractures of the radius which have come under my 
observation, not including gunshot fractures, or fractures demanding 
immediate amputation, three belonged to the upper third, three to the 
middle third, and eighty to the lower third. Three were compound, 
and' eighty-three simple. Forty-eight are recorded as occurring in 
males, and thirty-five in females; thirty-nine as having occurred in 
the left arm, and twenty -four in the right. 

Fracture of the neck of the radius, as a simple accident, uncompli- 
cated with any other fracture or dislocation, is exceedingly rare ; yet, 
owing to the depth of the superincumbent mass of muscles, and the 
difficulty of determining, where so many bones and processes approach 
each other, precisely from what point the crepitus, if any is found, pro- 
ceeds, surgeons have often been deceived, and they have believed that 
they were the fortunate possessors of this rare pathological treasure, 
when the autopsy has too soon disclosed their error. Both B. 
Cooper and Robert Smith have alluded to this difficulty, and the 
case reported by Dr. Markoe to the New York Pathological Society, 
and published in the American Medical Monthly, will serve to illus- 
trate the same point ; in which case the signs of a fracture of the 
radius at its neck were such as to deceive that experienced surgeon, 
yet the autopsy disclosed the fact that it was a dislocation of the head 
of the radius forwards, with a fracture of the ulna. Indeed, its exist- 
ence as a form of fracture was doubted by Sir Astley Cooper, and by 
others has been actually denied. I have seen no specimen obtained 
from the cadaver, except the doubtful one contained in Dr. Watts' 

1 Transactions of the American Medical Association, vol. i. p. 174. 



FRACTURES OF THE NECK OF THE RADIUS. 



265 



Fig. 75. 



cabinet, and of which I have furnished an account, accompanied with 
a drawing, in my report to the American Medical Association, 1 and 
the specimen owned by Dr. Mutter, of Philadelphia, of which he has 
kindly furnished me the following description : " History unknown. 
The line of fracture seems to have passed through the neck of the left 
radius, just at the upper extremity of the bicipital protuberance. Union 
with deformity has resulted. Owing to the 
fracture having taken place within the inser- 
tion of the biceps, that muscle' appears to 
have drawn forward and upward the lower 
end of the short upper fragment. In conse- 
quence of this movement, the articulating 
facet of the head of the radius is tilted back- 
wards, so as no longer to be in contact with 
the humerus. As a secondary consequence, 
the anterior edge of the head of the radius 
rests permanently against the articulating 
surface of the humerus. At this new point 
of contact a new surface of articulation is 
seen to have been formed, while the original 
articulating facet is directed backwards, and 
lies at right angles to the one of more recent 
formation. At the inner edge of the new 
articulation of the head of the radius with 
the humerus, contact with the ulna has 
developed another surface of articulation. 
The upper and lower fragments are united 
at an angle, and the radius does not appear 
to have lost in length." 

Yelpeau has once demonstrated the exist- 
ence of this fracture in a dissection, but the 
fracture was accompanied with a fracture 
also of the coronoid process; and Berard 
obtained possession of a similar specimen. 
I do not remember to have seen a notice of 

any others. Malgaigne affirms, with his usual frankness, that although 
he has occasionally believed that he had met with it, the autopsy, 
whenever it has been obtained, has shown that it was rather a sub- 
luxation than a fracture. On the other hand, Mr. South calls it a "not 
unfrequent accident," but in confirmation of this declaration he cites 
no examples. 

While, therefore, the presence of what appear to be the rational 
diagnostic signs has compelled me to record one case as an uncompli- 
cated fracture of the neck of the radius, and two others as fractures at 
this point accompanied either with a fracture of the humerus or a dis- 
location of the ulna, 1 am prepared to admit that some doubt remains 
in my own mind as to whether in either case the fact was clearly ascer- 
tained; nor do I think, speaking only of the simple fracture, that it will 




Fracture of neck of radius (Mut- 
ter's cabinet.) a. Original articu- 
lating facet, b, b. New articulating 
facets, c. Projecting fragments. 



18 



1 Transactions, vol. ix. pp. 157 and 229. 



266 FRACTURES OF THE RADIUS. 

ever be safe to declare positively that we "have before us this accident, 
lest, as has happened many times before, in the final appeal to that 
court whose judgment waits until after death, our decisions should be 
reversed. 

Nothing, perhaps, could more fully illustrate the difficulty of diag- 
nosis in the case of injuries received in the neighborhood of the head 
of the radius than the testimony given in the case of ISToyes vs. Allen, 
tried in the Supreme Court at Cambridge, January, 1856, before Judge 
Bigelow. Mr. Nbyes injured his elbow, January 7, 1854, and Dr. 
Allen, who was called immediately, believed that the ligaments of the 
joint had been torn, but that no bones were broken or displaced. On 
the following morning he was dismissed, and Mr. Noyes went home. 
Three weeks later it was seen by Dr. Dow, who also thought there 
was no fracture. About eight weeks after the accident a physician 
examined the arm, and declared the neck of the radius broken, and 
the fragments displaced ; and when the case was finally brought to 
trial, he testified still that such was certainly the fact ; and five other 
physicians, not one of whom, however, we are told, was a member of 
the State Medical Society, testified positively that the radius was 
broken at its neck, producing a bony protuberance ; that such an 
injury only could account for the symptoms manifested at the time of 
the accident, and that no other fractures or injuries of the joint could 
explain so well the present appearances of the arm. While, on the 
part of the defence, six of the most intelligent medical gentlemen of 
the State, Drs. Kimbal and Huntington, of Lowell, and Drs. Town- 
send, Lewis, Clark, and Gay, of Boston, testified that the head and 
neck of the radius were not displaced, nor was there any evidence 
that this bone had ever been broken. There is every reason to believe 
that these latter gentlemen were correct ; yet it is to be presumed 
that the gentlemen who first testified were not without some grounds 
for their opinions so confidently expressed. 

The case was given to the jury after a trial of five days, who 
promptly returned a verdict for the defendant. 1 

When this fracture occurs, the upper end of the lower fragment will 
probably be carried forwards by the action of that portion of the 
biceps which has its insertion into the tubercle ; and the displacement 
in this direction must necessarily be increased in proportion as the 
arm is straightened. In the cabinet specimen belonging to Dr. Mutter, 
the line of fracture, commencing in the neck, has terminated in the 
tubercle; consequently the biceps, having still some attachment to 
the upper fragment as well as the lower, has drawn them both for- 
wards. 

The same anterior displacement I have noticed in all of the sup- 
posed living examples, but whether both fragments or only one had 
suffered displacement I am unable to say. 

A girl, set. 11, living in Ontario Co., N. Y., fell from a tree, and 
injured her right arm. Her surgeon, who regarded it as a fracture of 
the neck of the radius, reduced the fragments, and placed the forearm, 

1 Amer. Med. Gazette, vol. vii. p. 299. 



FRACTURES OF THE HEAD OF THE RADIUS. 



267 



at a right 



angle with the 



Fig. 76. 



arm. . On the twenty-eighth day, all dress- 
ings were removed, and the patient was dismissed; the fragments 
seemed to be in place. The parents, finding the elbow stiff, now made 
violent and successful efforts to straighten the arm. 

Fifteen months after the accident, the child 
was brought to me. There was at this time a 
bony projection in front, opposite the neck of 
the radius, which I believed to be the point of 
fracture. The hand was forcibly pronated, and 
she had only a limited amount of motion at the 
elbow-joint. The anchylosis was probably due 
to inflammation directly resulting from the 
severe contusion ; but it is quite probable that 
the forward displacement of the fragments was' 
alone due to the too early and too violent at- 
tempts to straighten the arm; at least, this was 
the explanation which I ventured to give to the 
parents at the time. 

The second case occurred in a lad eight years 
old, living in Wyoming Co., N. Y. His parents 
brought him to me ten weeks after the injury 
was received, and I then found the forearm bent 
to a right angle with the arm, and anchylosed 
at the elbow-joint. The hand was also forcibly 
pronated, and could not be supinated. In front, 
and opposite the neck of the radius there was 
a distinct bony projection, which I believed to 
be the point of union of the bony fragments. 
The external condyle seemed also to have been 
broken. 

The third example, treated originally by Dr. 
Nott, of Buffalo, was seen by me six months 
after the accident. The upper end of the lower 
fragment seemed to be displaced forwards. 
There was very little motion at the elbow-joint, 
and both pronation and supination were com- 
pletely lost. 

I have seen, in Dr. Mutter's cabinet, two spe- 
cimens of fracture of the outer half of the head 
of the radius. In one case, the small fragment 
is slightly displaced downwards in the direction 
of the axis of the bone; and, in the other, the fragment is thrown 
outwards, or to the radial side. Both are firmly united in their new 
positions. 

In the treatment of fractures of the neck of the radius, we must not 
neglect to flex the forearm upon the arm, so as to relax, as completely 
as possible, the biceps, whose advantageous insertion into the tubercle 
of the radius would be certain to produce displacement, unless this 
position was adopted. A single dorsal splint, properly padded, should 
support the forearm, while the surgeon, having placed a compress 



&- i«~. 



Fracture of head of radius. 
(Mutter's collection. Speci- 
men A., No. 105.) 



268 FRACTURES OF THE RADIUS. 

over trie upper end of the lower fragment, proceeds to secure the whole 
with a roller. 

Especial care must also be taken to prevent the forearm from being 
extended before the bony union is fairly consummated, lest the biceps, 
now firmly contracted, should draw the lower fragment forwards, as 
it must inevitably do while the bony union is imperfect ; an accident 
which, there is some reason to believe, occurred in one of the examples 
which I have already cited. 

If the patient be a child, or if there is any reason to suppose that 
these rules will not be faithfully complied with, it would be well to 
secure the arm in this position with a right-angled splint. 

When the fracture occurs in any portion of the radius below the 
insertion of the biceps, and above the insertion of the pronator radii 
teres, Mr. Lonsdale suggests the propriety of placing the forearm in a 
condition of supination, at least so far as is practicable, for the purpose 
of securing a proper apposition of the fragments. His argument in 
favor of this practice is ingenious, and deserves consideration. 

When the bone is broken anywhere in this portion, the action of 
the pronators upon the upper fragment ceases ; while that of the biceps, 
which is a powerful supinator, continues ; consequently the upper frag- 
ment becomes at once, and completely, rotated outwards or supinated. 
Now, if the hand, to which the lower end of the radius alone remains 
attached, should be forcibly pronated, the radius will also be rotated 
inwards upon its own axis ; and although it might be possible in this 
condition to bring the broken ends into contact, and a bony union, 
without deformity, might be consummated, yet the power of supi- 
nation must be forever lost ; since the union has been effected while 
the head and upper fragment are already in a state of complete supi- 
nation, and if such is the fact it is evident that the whole bone, to- 
gether with the hand, will be incapable of any further supination. 

It is not, indeed, the practice with any surgeons, so far as I know, 
to treat this fracture with the hand placed in a position of extreme 
pronation ; but the case has been supposed for the purpose of render- 
ing the argument more intelligible. The usual practice is to place 
the forearm and hand in a position midway between supination and 
pronation, and then to lay it across the body at a right angle with the 
arm ; but it is plain that the same objection, differing only in degree, 
will apply to this position as to that of pronation. The axes of the 
two fragments are not made to correspond, since, while the lower frag- 
ment is only half rotated outwards, the upper fragment is completely, 
and the result of the union must be the loss of one-half the power of 
supination in the hand. 

It is only, then, by complete supination of the hand during treat- 
ment that this difficulty can be avoided, and I have no doubt that we 
ought to adopt this plan whenever it is practicable to do so, or when- 
ever we are not hindered by serious obstacles ; and the only obstacle 
which occurs to me as likely to interpose itself, is the. practical one 
which most surgeons must have experienced in treating all injuries of 
the forearm, whether fractures, or only severe contusions of the 
muscles, &c, namely, the constant and almost uncontrollable tendency 




FRACTURES OF THE HEAD OF THE RADIUS. 269 

of the hand to assume the prone or semi-prone position. This is due, 
no doubt, to the great preponderance of power in the pronators ; and 
such is the resistance which they afford to supination that it is often 
quite impossible to lay the hand upon its back while the forearm is 
across the body, and if accomplished, the position generally becomes 
in a few hours so painful as to be intolerable. By extending the 
arm, however, and laying it upon a pillow, the hand will be found 
again to rest easily upon its back, because in this way we avail our- 
selves of the outward rotation of the humerus at the shoulder-joint. 

It has already been stated that of the whole number of fractures of 
this bone seen by me, amounting in all to eighty -six, only three be- 
longed to the middle third. An observation which is in striking con- 
trast with the remark of Chelius, that it is broken most frequently in 
its middle. 

If the fragments are com- Fi S- 77 « 

pletely separated at this 
point, the lower end of the 
upper half is drawn forward 
by the action of the biceps 
aided by the pronator radii 
teres, in case the fracture is 
below its insertion ; while 
the lower fragment is tilted 

toward the Ulna by the COn- Fracture of the shaft of the radius. (From Gray.) 

joined action of the supi- 
nator radii longus, and pronator quadratus. But as to the direction 
of the displacement much will depend upon the direction of the force 
by which the fracture has been occasioned. 

A laboring man, set. 35, broke the radius near the lower end of the 
middle third. On the same day I replaced the fragments as well as 
I could in the midst of the swelling which had already occurred, and 
applied two broad and well-padded splints, one to the palmar and one 
to the dorsal surface of the forearm. 

On the twenty-eighth day I first discovered that the fragments were 
projecting in front, and I at once proposed to thrust them back by 
force, but the patient declined allowing me to do so. I then applied 
a compress near the summit of the projection, but not exactly upon 
it, lest it should cause ulceration, and secured over this a firm 
splint. At first this seemed to produce a change in the fragments, 
but after a couple of weeks I found there was no improvement, and it 
was discontinued. About six months after the fracture occurred, this 
man had the same arm terribly lacerated in a railroad accident, and I 
was obliged to amputate near the shoulder-joint; and I thus obtained 
the broken radius. The bone was firmly united, but with an angle, 
salient forwards, of about ten degrees. There was no inclination 
toward the ulna. 

My impression is that these fragments were never completely re- 
placed, a point which I could not well determine at first on account of 
the rapid effusion. If they had been, I think they could have been 
retained in place with the appliances used. Almost every day the 
limb was examined, and as often as every fourth or fifth day the 



270 FRACTURES OF THE RADIUS. 

dressings were removed and carefully reapplied. And only once did 
they become so loose as not to afford the requisite support, and this 
at a period too late to have occasioned the deformity. 

We ought not to be deceived, therefore, and promise too confidently 
a perfect limb, even when but the radius is broken, since we may not 
always be certain that the ends are w T ell replaced, or perhaps they may 
become displaced subsequently, and in either case we are not likely 
to discover the deformity until the swelling has subsided, and it is too 
late to apply the remedy. 

In the treatment of fractures of the middle third, the same rules, 
with only slight modifications, will be applicable, as in fractures of both 
bones. Two straight, long, and broad splints must be applied after 
being carefully padded; and especial attention should be paid to the 
tendency of the fragments to become displaced forwards and toward 
the ulna through the action of both the biceps and the pronator radii 
teres ; a tendency which may in some measure be provided against by 
flexion of the arm, but which must be overcome chiefly by steady and 
well-adjusted pressure, near, but not upon, the ends of the fragments. 

Fractures of the lower third, occurring above the line of Colles' 
fracture, are almost as rare as fracture of the middle or upper thirds. 
I have recorded five ; one of w r hich it will be proper to relate as a 
representative example. 

Geo. Yogel, set. 30, was admitted to the Buffalo Hospital of the Sis- 
ters of Charity, Nov. 2, 1852, with a fracture of the right radius about 
three and a half inches above its lower end. The hand was prone, 
and inclined to the radial side; while the broken ends of the radius fell 
against the ulna, from which it was found difficult to separate them. 
The lower end of the ulna was prominent, and projecting upon the 
ulnar margin of the hand. 

I was unable completely to separate the fragments of the radius from 
the ulna, by either pressure with my fingers between the bones, or by 
seizing upon them with my thumb and fingers. Having, however, 
adjusted them as well as possible, I flexed the arm, and applied a 
broad and well-padded splint to the palmar surface of the forearm, 
securing it in place with a paste bandage. These dressings were finally 
removed at the end of four weeks, when I found scarcely any displace- 
ment or deformity remaining. 

Most of these fractures, when properly treated, result in perfect 
limbs. In a certain proportion, however, it will be found impossible 
effectually to resist the action of the pronator radii teres and of the 
quadratus, and the fragments will unite at an angle resting against 
the ulna, and sometimes, by the interposition of intermediate callus, 
they will become firmly united to the ulna. Occasionally, also, espe- 
cially where the fracture has been produced by a fall upon the hand, 
and the radio-ulnar ligaments of the wrist have been torn or stretched, 
the lower end of the ulna will be found to project permanently, and 
the hand to fall more or less to the radial side. 

Of the eighty fractures belonging to the lower third of the radius, 
seventy-five were near the lower end, or within from half an inch to 
one inch and a half from the articular surface, all being included in 
those fractures called "Colles' fractures," most of which were no doubt 



COLLES' FRACTURE. 



271 



true fractures, and probably a small proportion separations of the 
epiphysis. 

In every instance, except one, which has come under my notice, 
where the cause of a Colles' fracture has been ascertained, it has been 
occasioned by a fall upon the palm of the hand. The exceptional 
case was in the person of Mrs. D. B., who fell in getting out of a street 
car in the city of New York, May 20th, 1865, striking upon the back 
of her hand while the hand was shut. The displacement was in the 
same direction as in cases caused by a fall upon the palm. Eobert 
Smith has seen a similar accident cause a displacement of the frag- 
ment forwards. 

Colles described this fracture as occurring always about one inch 
and a half above the carpal end of the bone ; but Eobert Smith, who 
has carefully examined all of the cabinet specimens he could find, 
about twenty-three in number, has never seen the line of fracture 
removed farther than one inch from the lower end of the bone, and 
in several specimens it was within one-quarter of an inch of this 
extremity. Dupuytren has also described the fracture as occurring 
from three to twelve lines above the joint. I think I have found the 
fracture generally as low as these latter surgeons have placed it, but 
occasionally as high as it was placed by Colles. 

Fig. 78. 




Fracture of the radius near its lower end. 



Case. A woman, get. 40, fell upon the side-walk, striking upon the 
palm of her left hand. She was brought immediately to my office, 
and I found the radius was broken about one inch and a half above 
the wrist. The lower fragment was tilted back considerably. Hand 
prone. 

Placing my thumb against the back of the lower fragment, it was 
easily restored to position, and with only a slight crepitus. When 
my thumb was removed it manifested no tendency to displacement. 
The arm was dressed with a curved palmar splint, secured in place 
with a roller applied moderately tight. On the seventh day a straight 
splint was substituted for the curved. The arm was examined almost 
every day, and the dressings occasionally renewed until the twenty- 
sixth day, when the splint was finally removed. The wrist was at 
this time only slightly anchylosed, and there seemed to be no deformity 
or imperfection remaining. Passive motion, which had been practised 
at each removal of the dressings, was directed to be continued. 

Case. A boy, set. 11, was brought to me having just fallen from a 
pair of stilts. His right radius was broken transversely, three-quarters 



272 FRACTURES OF THE RADIUS. 

of an inch above the wrist, and the lower fragment was much tilted 
back ; the lower end of the ulna was prominent, and the hand fell to 
the radial side. 

Pushing from behind, the lower fragment was made to resume its 
place, and the deformity immediately disappeared. It was noticed, 
however, that it required unusual force to accomplish this, but it was 
not found necessary to use extension. There was also, accompanying 
the reduction, a slight crepitus. 

The treatment was the same as in the first case, except that the 
curved splint was employed throughout. Little or no deformity ex- 
isted when the dressings were removed. 

Case. Greorge Lofinch, aet. 42, fell upon an icy side-walk, striking 
upon the palm of his left hand. Fracture three-quarters of an inch 
above the lower end. Fragment displaced backwards. A friend had 
partially replaced the fragment by pushing upon it, before he came to 
me. Within half an hour after the accident he was at my office, and 
I restored the lower end of the bone very easily to place by pushing 
from behind with my thumb. No extension was necessary. It would 
not, however, remain in place unless the forearm was pronated so that 
the w r eight of the hand could aid in the retention. 

I applied my own palmar splint. The recovery was rapid and 
complete. 

Case. Lewis Brittin, set. 60, fell from a fourth story window, 
breaking, among other bones, the radius of the right arm three-quar- 
ters of an inch above the joint. This fracture was not discovered 
until the fourth day. Crepitus and motion were then distinct, but 
there was no displacement. The wrist was considerably swollen. No 
splints were applied ; and the bone united promptly, leaving no de- 
formity or anchylosis. 

Case. Margaret Eeed, aet. 48, fell, September 23, 1855, striking on 
the palm of the left hand, and breaking the radius about one inch from 
its lower end. One week after, she came under my care at the hos- 
pital. The arm had been previously dressed carefully by one of my 
colleagues, with curved dorsal, and palmar splints ; but, on examina- 
tion, we found the fragments a good deal displaced. It was found 
necessary now to use both extension, and pressure from behind to re- 
store the lower fragment to position. This we finally succeeded in 
doing, and immediately splints were again snugly applied. Two days 
after, on opening the dressings, the lower fragment was a second time 
found displaced backwards. It was again reduced, but only by using 
great force. Fifteen days later, we were pleased to find the bone firm 
and without deformity. 

Margaret left the hospital on the 4th of November, with her hand 
and wrist still swollen, and with a good deal of stiffness at the elbow 
and wrist-joints. 

Case. Charles Stratton, a healthy and temperate laborer, aet. 36, 
fell forwards from a wagon, Nov. 22, 1854, striking upon the palm of 
his hand, and breaking the radius a little more than one inch above 
the joint. I found the lower fragment displaced backwards, and it was 
easily reduced by pressure in the opposite direction. The fore part of 



COLLES 1 FRACTURE. 273 

the wrist being quite tender to pressure, the splint was applied to the 
dorsal surface of the forearm. The splint was curved (pistol-shaped"!, 
and the surface which was applied to the arm was padded with care ; 
it was secured in place by a few light turns of a roller, and laid across 
the body in a sling. 

The arm was seen by- me on each of the succeeding seven days, and 
on the third, fifth, and seventh days, the splint was removed com- 
pletely; but on this last day an erysipelatous inflammation had com- 
menced in the neighborhood of the wrist. The splint and roller were 
therefore not reapplied, but the limb was laid upon a broad board, 
cushioned and covered with oiled silk, and cool water irritations were 
directed. The inflammation soon subsided, but the splint was never 
resumed, as the fragments were found to stay in place perfectly with- 
out its aid. At the end of five weeks, union seemed to be consum- 
mated ; and one year later the bone was found to be perfectly straight, 
yet the wrist-joint and the finger-joints remained stiff) so much so that 
he was unable to perform any labor. The stiffness was, however, 
gradually disappearing; while all swelling and tenderness had long 
ceased. 

The observations of M. Vollemier also have shown that, instead of 
being oblique, as has generally been supposed, the fracture is almost 
uniformly transverse from the palmar to the dorsal surfaces of the 
bone, and only occasionally slightly oblique in its other diameter, or 
from the radial to the ulnar side. I have seen, however, in the mu- 
seum of the College of Physicians of Philadelphia, a specimen of this 
fracture in which the line of fracture is transverse, from side to side, 
but very oblique from before backwards, and from below upwards. 
There is also a line of incomplete fracture extending into the joint. 
It is united by bone, with the usual displacement backwards. 

The observations of both K. Smith and Vollemier have shown, 
moreover that the displacement of the lower fragment is seldom suffi- 
cient to enable it to escape completely from the upper ; and that where, 
in extremely rare instances, and in consequence of extraordinary vio- 
lence, such complete separation does occur, a disruption of those liga- 
ments which attach the lower fragment to the ulna occurs also, and 
the deformity becomes at once very great, so that it no longer presents 
the peculiar features of Colles' fracture, but resembles a dislocation. 

In the so-called Colles' fracture, the lower and outer border of the 
radius, or its styloid apophysis, is swung around or tilted, as it were, 
upon the ulna; the lower and inner border of the same fragment being 
retained in place by the radio-ulnar ligaments, which do not usually 
suffer a complete disruption, but only a stretching or partial laceration. 
The upper or broken margin of the lower fragment, and also the 
ulnar margin, undergo very little displacement ; while the lower or 
articular surface, and the radial margin, are carried backwards, up- 
wards, and outwards. 

Surgeons have spoken of a falling in of the upper end of the lower 
fragment toward the ulna, as an almost inevitable result of the action 
of the pronator quadratus, and against which tendency they have 
sought carefully to provide; but there is much reason to believe that 



274 FRACTURES OF THE RADIUS. 

any considerable degree of displacement in this direction is a rare 
event, and that, when it does exist, it is in consequence mostly of the 
direction of the force which has produced the fracture, rather than of 
the action of this muscle, only a few of the fibres of which are usually 
attached to the lower fragment, and, in some instances, when the 
fracture is within a half or quarter of an inch of the articulation, not 
any. Besides, there is actually in these latter cases, no interosseous 
space into which the fragment may fall, and its displacement toward 
the ulna becomes, therefore, impossible. 

Still, however, if one were disposed to speculate upon the condition 
of these parts after the fracture, it might perhaps be easy to persuade 
ourselves that the action of the pronator quadratus upon the upper 
fragment, whose broken extremity was not completely, or at all dis- 
engaged from the lower, would carry both fragments together toward 
the ulna. But whatever might be the result of our speculations, still 
the fact, as proved by specimens, is not generally so ; and this is not 
the first time that facts and theories have disagreed. 

The truth is, that it is unusual to find any of the museum speci- 
mens of this fracture thus united. But they may be found constantly 
tilted back in the manner I have described, occasionally tilted for- 
wards, and, still more rarely, slightly displaced upon their broken 
surfaces antero-posteriorly. 

The general absence - of this internal displacement may find its ex- 
planation in the direction of the force which generally produces this 
fracture in the occurrence of the fracture sometimes at a point so low 
as to render its displacement in this direction impossible, and in the 
breadth of the bone, at the seat of the fracture, which does not permit 
it to fall laterally without actually increasing its length ; a circum- 
stance which its secure ligamentous attachment to the ulna at its op- 
posite extremities, and its complete apposition to the wrist and elbow- 
joint, do not allow. 

The mistake of those surgeons who have attempted to describe this 
fracture has originated in the appearance presented in nearly all re- 
cent fractures occurring at this point. The hand falls to the radial 
side, and seems to carry the lower end of the lower fragment with it, 
while the lower end of the ulna becomes unnaturally prominent in 
front and to the ulnar side ; a condition of things which has naturally 
enough been ascribed to the displacement of the upper end of the 
lower fragment in the direction of the interosseous space. 

But this same radial inclination of the hand, and prominence of the 
ulna, are present frequently when the radius is broken at its lower 
end, and no displacement in any direction has taken place; and I have 
even observed it in simple sprains of the wrist, and in the hands of 
old or feeble persons where all the ligaments have become relaxed. 

It is seen, however, in a more marked degree when the bone is 
actually both broken and displaced backwards in its usual direction. 
In short, the deformity in question is due, in a large majority of in- 
stances, to the relaxation, stretching, or more or less disruption of the 
radio-ulnar ligaments, which permits the hand to fall to the radial 
side by a simple rotatory movement over its articular surface. For 



COLLES' FRACTURE. 



275 



this reason, also, because these ligaments once lengthened or broken 
can never, or only after a lapse of many years, be completely restored, 
this deformity may be expected to continue, however exact and perfect 
may be the bony union. 

It must be added, however, that so long as the tilting of the frag- 
ment remains, the articular surface is actually presenting somewhat to 
the radial side. While in the normal condition it presents downwards, 
forwards, and inwards, it now presents, when the displacement is con- 
siderable, downwards, backwards, and outwards. 

Diday maintained that there existed usually in this fracture an over- 
lapping or shortening of the bone in its entire diameter, and Vollemier 
thought that the specimens which he had examined proved that an 
impaction was almost universal. 

Both of these opinions have been combated by Eobert Smith ; the 
shortening observed by Diday being found only on that side of the 
bone to which the hand inclines, and being, according to E. Smith, 
the result of the motion of the lower fragment already described ; and 
the appearance of impaction being due to the ensheathing callus which 
is deposited usually, if the displacement is allowed to continue, in the 
retiring angle opposite the seat of fracture. 

These are questions, however, requiring for their decision a very 
careful study of specimens, and in relation to which further observa- 
tions may be necessary. Indeed, some recent observations made by 
Mr. Callender, of Saint Bartholomew's Hospital, London, go far to 
sustain the opinion of Diday, that some impaction generally exists, 
but rather upon the posterior margin than upon 
either the radial or ulnar side. 1 

Meanwhile there is no doubt that occasional ex- 
amples may be found illustrating one or more of all 
these varieties of displacement, and that to the im- 
paction is sometimes added a comminution of the 
lower fragment, the lines of the fracture extending 
freely into the joint. One of the most curious exam- 
ples of which has been reported by Dr. Bigelow, 
of Boston. The patient had fallen, and being other- 
wise seriously injured, ultimately died in the Massa- 
chusetts Hospital. At first he had only complained 
of lameness at the wrist, as if it had been severely 
sprained ; but at the end of several days the joint 
became swollen, and from the persistence of the 
swelling Dr. Bigelow was led to diagnosticate a 
stellate crack in the articulating extremity of the 
radius, he having met with a similar case two 
years before, when a patient with the same symp- 
toms had died of other injuries, and exhibited a 
crack in the same place, but less extensive than 
in this case. There was found, in this last example, a star-shaped 
fissure on the articulating surface, without displacement. These fis- 




Bigelow's case of com- 
minuted fracture of the 
lower eud of the radius. 



1 Callender, St. Barth. Hosp. Rep., p. 281, 1865. 



276 FKACTUKES OF THE EADIUS. 

sures penetrated the shaft for an inch or more. Dr. Bigelow thought 
that the bones of the wrist acted as a wedge to spread the correspond- 
ing hollow of the articulating extremity ; and that this specimen would 
explain the persistence of some cases of sprained wrist. 1 

Robert Smith has described a fracture occurring at the same point, 
and probably possessing the same characters as Colles' fractures ; in 
which the lower fragment is thrown forwards instead of backwards, 
and which has generally been the result of a fall upon the back of 
the hand. There is no such specimen, however, in any of the patho- 
logical collections in Dublin, nor has Mr. Smith ever seen a specimen 
obtained from the cadaver, although he reports a case which fell under 
his observation in practice. 

I have myself seen one such case, 2 but I regret to say that my 
examination of the condition of the arm was not such as to enable 
me to add anything to the information already possessed upon this 
subject; indeed, until we have an opportunity of studying it in the 
cadaver, we cannot speak very definitely of its anatomical characters. 

Nelaton observes that all the varieties of this fracture which he has 
seen are often accompanied with fracture of the styloid apophysis of 
the ulna, and with a tearing of the triangular ligament. I am not 
aware that any other writer has made the same observation in relation 
to the frequent occurrence of a fracture of the styloid apophysis of the 
ulna, and I think the accident is not so common as the remark of 
Nelaton would lead us to suppose. 

Dr. Butler, House Surgeon to the Brooklyn Hospital, reports a case 
of fracture of the right radius at the junction of the middle and 
lower thirds, accompanied with a fracture also of the styloid apophy- 
sis in the same bone. The accident occurred in a lad fourteen years 
old, who had fallen from a height of thirty feet upon the pavement. 
The lower fracture commenced at the base of the styloid process of the 
radius, and extended down obliquely into the wrist-joint, breaking off 
about one-fifth of the articular surface. The process was drawn up 
on the posterior surface of the radius, about one inch and a half, by 
the supinator radii longus muscle. It was movable, but in consequence 
of the contusion and swelling, could not be returned to its place. The 
hand occupied the same position that it does in Colles' fracture. 

On the eighth day an attempt was made to force down the process 
with a compress secured by adhesive plaster straps ; but it could not 
be done. The hand and arm were confined also to a pistol shaped 
splint; ulcerations ensued from the pressure of the compress, and the 
process was laid bare, but it finally became united in its abnormal 
position ; the motions of the wrist, however, were not impaired, and 
the power of pronation and supination soon returned. 3 

I believe I have seen two examples of a fracture commencing on 
the radial side of the bone and terminating in the joint, the separated 
fragment including considerable more than the apophysis ; but neither 
of these cases has been verified by an autopsy. 

1 Boston Med. and Surg. Journ., vol. lviii. p. 99. 

2 Trans. Am. Med. Assoc, vol. ix. p. 145. 
8 New York Journ. of Med., 1857. 



COLLES' FRACTURE. 277 

A boy, set. 18, fell twelve feet, striking upon the right hand aDd 
wrist. I examined him at the hospital soon after, and thought I could 
distinctly feel the line of fracture extending very obliquely downwards, 
from the radial side into the joint, and without traversing the entire 
diameter of the bone. The fragment thus separated fell backwards, 
and the hand inclined to the radial side. Reduction was immediately 
accomplished by pushing the fragment forwards, and the arm was 
dressed with straight palmar and dorsal splints, with compresses, &c. 
He was soon dismissed. 

Five months after I found the bones united without displacement, 
and the motions of the joint were perfect. 

A man, set. 38, fell upon the palm of his left hand. On the same 
day he was admitted to the Buffalo Hospital of the Sisters of Charity, 
and the diagnosis was confirmed by Drs. Lay and Lemon. The symp- 
toms were the same as in the first case, and we adopted the same treat- 
ment. On the thirty-first day, it was noted in the hospital record, that 
"the splints have been for some time removed, but the wrist remains 
swollen and stiff. The lower end of the ulna is prominent, but the 
fragments of the radius seem to be in exact line." 

In the first volume of the Philadelphia Medical Examiner (1838) 
will be found a description by J. Rhea Barton, of Philadelphia, of a 
form of fracture occurring through the lower end of the radius, which 
is probably much less common than Colles' fracture, and which had 
hitherto escaped the notice of surgeons. Its peculiarity consists in the 
line of fracture extending very obliquely from the articulation, up- 
wards and backwards, separating and displacing the whole, or only a 
portion, as the case may be, of the posterior margin of the articulating 
surface. I have not recognized this fracture in any instance which 
has come under my own observation, nor have I been able to find a 
cabinet specimen in any pathological collection. Dr. Barton was not 
able to prove the correctness of his diagnosis by an autopsy, and the 
only well-authenticated example which I can find upon record is that 
to which Malgaigne has alluded, as having been seen by M. Lenoir, 
and of which an account was published in the Archives Oenerales de 
Medecine in 1839. M. Lenoir believed it to be a simple luxation of the 
hand backwards, but the patient having died, he was able to correct 
his diagnosis by an autopsy. A considerable fragment had been 
broken from the posterior lip of the articular surface, the line of frac- 
ture being from below upwards, and from before backwards. This 
fragment had become displaced upwards and backwards, carrying 
with it the carpal bones, and producing thus, the appearance of a 
simple dislocation. 1 I believe that the accident so carefully described 
by Barton was either a Colles' fracture, or a fracture simply of the- 
radial margin, of which I have given two supposed examples, with 
the usual signs of which his account so exactly coincides, and that it. 
was not a fracture of the posterior lip of the articulating surface, as he 
believed. 

Eighty examples of fracture of the lower third of the radius have 

1 Malgaigne, Traite des Frac, etc., torn. ii. p. 700. 



278 FRACTURES OF THE RADIUS. 

furnished no cases of non-union, nor indeed do I remember ever to 
have seen the union delayed ; yet only eighteen are positively known 
to have left no perceptible deformity or stiffness about the joint : it is 
probable, however, that the number of perfect results might be some- 
what extended. In one example, the case of a man whose arm was 
broken in Germany, when he was only ten years old, the fragments of 
the radius were driven into each other, or overlapped one inch, and 
the ulna had been displaced downwards toward the fingers the same 
distance. This was examined twelve years after the accident, and he 
had then a very useful arm. Twice I have found the wrist and finger- 
joints quite stiff after a lapse of one year ; in one case I have found 
the same condition after two years ; in one case after three years, and 
in two cases after five years. 

If we confine our remarks to Colles' fracture, the deformity which 
has been observed most often, and, indeed, with only rare exceptions, 
being found in some degree more or less in several of those cases 
which I have marked as perfect, consists in a projection of the lower 
end of the ulna inwards and generally a little forwards. In a large 
majority of cases this is accompanied with a perceptible falling of the 
hand to the radial side, while in a few it is not. After this, in point 
of frequency, I have met with the backward inclination of the lower 
fragment. Eobert Smith found this displacement almost constant in 
the cabinet specimens examined by him; and it is very probable that 
nearly all of the examples examined by myself would present more or 
less of the same deviation upon the naked bone ; but in the living 
examples a slight deviation would be concealed by the numerous 
tendons which cover this part of the arm, and perhaps by some per- 
manent effusions, of which I shall speak more particularly presently. 

There remains for a long time, in a majority of cases, a broad, firm, 
uniform swelling on the palmar surface of the forearm, commencing 
near the upper margin of the annular ligament and extending upwards 
two inches or more. This swelling continues much longer in old and 
feeble persons than in the young and vigorous. It is pretty generally 
proportioned to the amount of anchylosis existing at the wrist and 
finger-joints, and it disappears usually pari passu, with these condi- 
tions. There can be no doubt that this phenomenon is due to an 
effusion, first serous, and subsequently fibrinous, along the sheaths of 
the tendons ; and it is as often present after sprains and other severe 
injuries about this part, as in fractures. In many cases, however, its 
prolonged continuance and its firmness have led to a suspicion that 
the bones were displaced, a suspicion which only a moderate degree 
of care in the examination ought easily to dispel. A similar effusion, 
but in less amount, is frequently seen also on the back of the hand, 
below the annular ligament. When both exist simultaneously the 
appearances of deformity and of displacement are greatly increased. 
Here, then, we shall find a partial explanation of the anchylosis in 
the wrist and finger-joints, which continues occasionally many months, 
or even years, ifj indeed, it is not permanent. An anchylosis pro- 
duced in a few instances by extension of the inflammation to these 
joints, but much more often by the inflammatory effusion and conse- 



279 

quent adhesions along the thecse and serous sheaths, through which 
the tendons all pass in their course to the hands and fingers ; and by 
simple contraction of the articular ligaments as a consequence of dis- 
use, or, as it is usually termed, by passive contraction of these liga- 
ments. The fingers are quite as often thus anchylosed after this frac- 
ture as the wrist-joint itself, a circumstance which is wholly inexpli- 
cable on the doctrine that the anchylosis is due to an inflammation in 
the joints. Indeed, I have seen the fingers rigid after many months, 
when, having observed the case throughout myself, I was certain that 
no inflammatory action had ever reached them. 

Nor is it any more difficult to show, I think, that the anchylosis of 
the wrist-joint is not often due to a malposition of its articular surfaces, 
as has frequently been asserted in the written treatises. 

The most superficial examination of the mechanism of this joint 
ought to satisfy us, that any moderate or even considerable malposi- 
tion of the lower fragment after a fracture of the radius, is not sufficient 
in itself to occasion anchylosis. It is true that in the fracture now 
under consideration, the direction of the articular surface of the radius 
is changed, and that, while it was directed downwards, forwards, and 
to the ulnar side, it is now, perhaps, directed downwards, backwards, 
and to the radial side. But of what consequence is this so long as the 
carpal bones, with which alone this bone is articulated, preserve their 
relations to the radius unchanged ? 

If any other evidence be demanded, it may be supplied by the 
experience of most surgeons in examples of anchylosis without dis- 
placement; in examples of displacement without anchylosis, but in 
which the anchylosis has yielded gradually to the lapse of time, while 
the displacement has continued. The following case is in point : 
James Ryan, a private in the 15th N. Y. volunteers, fell from a height 
into a ditch during the battle of Fair Oaks, Va., May 31, 1862, striking 
upon the palm of his left hand, and causing a simple fracture near the 
lower end of the radius, accompanied probably with impaction. I do 
not know what treatment was adopted, but when he came under my 
observation in March, 1863, at the Central Park General Hospital, 
New York, I found the most extraordinary deflection of the hand to 
the radial side which I have ever seen after this fracture. The hand 
could be turned laterally, to a right angle with the arm ; yet the 
motions of flexion and extension at the wrist-jaint were nearly as per- 
fect as in the opposite arm, and the hand was in all respects as useful 
as before the accident. 

To what I have said as to the prognosis in these acccidents, I may 
be permitted to add the opinion of our distinguished countryman, 
Dr. Mott, given in a clinical lecture before his class in the University 
of New York. 

" Fractures of the radius within two inches of the wrist, where 
treated by the most eminent surgeons, are of very difficult manage- 
ment so as to avoid all deformity ; indeed, more or less deformity may 
occur under the treatment of the most eminent surgeons, and more or 
less imperfection in the motion of the wrist or radius is very apt to 
follow for a longer or shorter time. Even when the fracture is well 



280 FRACTURES OF THE RADIUS. 

cured, an anterior prominence at the wrist, or near it, will sometimes 
result from swelling of the soft parts." 

To which the reporter, himself a surgeon in the city of New York, 
adds : — 

"As the above opinion of Professor Mott coincides with my own 
observations, both in Europe and in this city, as well as with many of 
our most distinguished surgical authorities, I venture to hope that it 
may assist in removing some of the groundless and ill-merited asper- 
sions which are occasionally thrown on the members of our profession 
by the ignorant or designing." 1 

Of gangrene as an occasional result of this fracture, I shall speak 
presently, in connection with the subject of treatment. 

The peculiar character of the displacement which characterizes 
Colles' fracture, and the constant difficulty experienced by surgeons 
in obviating deformity, have led to much speculation and ingenious 
invention; and modern surgeons, especially have thought it necessary 
to introduce here an essential modification of the usual apparel for 
broken forearms. This modification consists in employing a pistol- 
shaped splint, instead of a straight splint, by means of which the hand 
may be thrown more or less strongly to the ulnar side. 

Heister 2 speaks of inclining the hand toward the ulna, while re- 
ducing a fracture of the radius, but when the reduction has been 
effected he recommends a straight splint. 

Among the first to advocate the permanent confinement of the hand 
in this position, were Mr. Cline, of London, 3 and M. Dupuytren, of 
Paris. 4 Mr. Cline, and after him Bransby Cooper, 5 and Mr. South, 6 
recommend the ordinary straight splints for the forearm, but the 
rollers by which the splints are secured in place are not permitted to 
extend lower than the wrist ; so that when the forearm is suspended 
in a sling, in a state of semi-pronation, the hand shall fall by its own 
weight to the ulnar side. 

Dupuytren, and after him, Chelius, adopt, in addition to the palmar 
and dorsal splints, the " attelle cubitale," or ulnar splint ; which is a 
gutter, composed of steel, iron, tin, or some other metal, and made to 
fit the ulnar margin of the forearm and hand, when the hand is drawn 
forcibly to the ulnar side. Blandin, 7 Nekton, 8 and Goyraud, 9 also, 
under certain contingencies employ the same. 

Most surgeons, however, employ either a palmar or a dorsal splint ; 
or both palmar and dorsal splints constructed with a knee, or pistol- 
shaped, and they thus avoid the necessity of the ulnar splint. Thus, 
Nekton,' Eobert Smith, 11 and Erichsen, 12 recommend this peculiar form 

1 Boston Med. and Surg. Journal, vol. xxv. p. 289. 

2 De Lavrentii Heisteri, Institutiones Chirurgicse, pars prima, p. 203, Amsterdam 
ed., 1739. 

3 Malgaigne, Traite de Frac. etc., torn. i. p. 614, Paris ed. 
1 Dupuytren, on Bones, London ed., p. 140. 

5 B. Cooper, Lectures on Surg., p. 232, Amer. ed. 

5 Chelius's Surg., vol. i. p. 613. 7 Malgaigne, op. cit , torn. i. p. 614. 

8 Nelaton, Eleni. de Path. Chir., torn. i. p. 747. 9 Ibid., p. 746. 

10 Nelaton, op. cit., p. 747. » R. Smith, op. cit., p. 168. 

12 Erichsen, Surgery, p. 215. 






COLLES' FRACTURE. 



281 



only in the dorsal splint; while Bond, 1 Hays, 2 E. P. Smith, 3 Gr. F. 
Shrady, 4 and others, especially among the Americans, place the pistol- 
shaped splint against the palmar surface of the forearm and hand. 




N^laton's splint for fracture of the radius. 
Fig. 81. 




Hay's splint. 

A few modern surgeons have not seen fit to adopt this peculiar 
principle of treatment, or this form of dressing under any of its modi- 
fications. Colles 5 recommends a straight palmar and dorsal splint, and 
does not incline the hand. Barton 6 advises the same, and Skey, havino- 
declared his preference for a couple of broad, straight splints, addsl 
"Great care should be taken to prevent the hand falling, and this 

1 Bond, Amer. Journ. Med. Sci., April, 1852. 2 Ibid., Jan. 1853. 

3 E. P. Smith, Buffalo Med. Journ., vol. ix. p. 225. 

4 Shrady, Am. Med. Times, 2 cases, Dec. 22, 1860. 

5 Colles, Lectures on Surgery, p. 325. 6 Barton, Phil. Med. Exam., 1838. 

19 






282 



FRACTURES OF THE RADIUS. 



object will be attained by inclosing the entire forearm and hand in a 
well-applied sling." 1 

Professor Fauger, of Copenhagen, has undertaken to treat this frac- 
ture in some sense without any splint, the forearm and hand being 

Fig. 83. 




E. P. Smith's splint. Surface applied to forearm. A. Forearm piece, made of felt, with incurvated 
margins. 



Fig. 84. 




E. P. Smith's splint. B. Opposite surface. D, the hand-block, is connected with the forearm piece by- 
two circular brass plates, which move upon each other, in order that the hand-block may assume any 
desired angle with the arm. In this way it may be adapted to either the right or left arm. It is fixed 
by a nul seen on the brass plate . The letters C indicate the extent of motion allowed to the hand-block. 

Fig. 85. 




Geo. F. Shrady's splint. To be applied to the palmar surface of forearm and hand ; the hand being 
dedected towards the ulna. A strip of adhesive plaster encircles the forearm and splint near the elbow. 
A loop is also formed for the ulnar margin of the wrist by passing one end of a strip of plaster, 3 inches 
in width, between the palmar surface of the wrist and the splint, over on the dorsum of the wrist ; both 
ends being then brought around and made adherent to the under surface of the splint. Lastly, the hand 
is secured to the hand-piece by a circle of plaster ; the dorsal splint, if required, can then be applied in 
the usnal way. Passive motion is made every second or third day. by grasping the apparatus at wrist, 
and freeing the hand. 

simply laid over a double inclined plane, so as to bring the wrist into 
a state of forced flexion. " The hand having been brought into a posi- 
tion of strong flexion, the forearm is placed, pronated, on an oblique 
plane, with the carpus highest, the hand being permitted to hang freely 
down the perpendicular end of the plane." 2 M. Yelpeau, in a report 



Skey, Operative Surgery, p. 161. 



2 Fauger, London Lancet, May 8, 1847. 



COLLES' FEACTUKE. 283 

of his surgical clinic at La Charite for the year ending September. 
1SI6, says this plan has been tried during the year, and "the result 
has not been very satisfactory. The experiment, however, has not 
been decisive upon this mode of treatment." 1 

Notwithstanding these exceptions, the practice seems to be pretty 
well established among the leading surgeons everywhere to employ in 
the treatment of this fracture the principle of adduction of the hand, 
and always to the attainment of the same purpose, namely, rotary 
extension, by which they hope to retain more securely the lower frag- 
ment in place. 

We come now to consider how far this peculiar treatment is capa- 
ble of answering the special indications of the case we are studying. 

It is assumed, as I have already intimated, that, by bearing the 
hand strongly to the ulnar side, the fragments of the radius are 
brought more exactly into apposition, and more easily and effectually 
retained ; an assumption which supposes two things to have been 
determined ; first, that there exists an overlapping of the fragments, 
either through the whole extent of their broken surfaces or especially 
toward the radial side, or that the upper end of the lower fragment 
is inclined to fall against the ulna, or that all of these several condi- 
tions coexist; and, secondly, that if such displacements do exist, they 
can be remedied by this manoeuvre. 

The first of these suppositions seems to have been sufficiently con- 
sidered by all those gentlemen who have particularly examined the 
specimens contained in the various pathological collections, and to 
whose careful investigations I have already frequently adverted. With 
rare exceptions, none of these displacements have been found to exist, 
although, as has been observed, a casual inspection of the arm when 
recently broken would often lead to an opposite conclusion. I do not 
here speak of impaction, which is usually upon the posterior margin, 
if it exists at all. 

In regard to the second supposition, namely, that where such dis- 
placements do exist, a forced adduction will aid in the retention of 
the fragments, I shall have to speak more cautiously, because, so far 
as I know, my opinions have received as yet no public and authorita- 
tive indorsement. In order that adduction may prove effective, there 
must be some point upon which to act as a fulcrum. It is of no use that 
we rotate the hand for the purpose of making extension unless there 
can be found a resistance or fulcrum upon which the rotary motion 
may be performed. Such a fulcrum exists, no doubt, but to determine 
its availability we must ascertain its character and position. 

It is not in the lower end of the ulna, for the ulna has no point of 
contact with the carpal bones, and when, in the natural state of these 
parts, the hand is inclined to the ulnar side, the lower end of the ulna 
rides freely downwards upon the wrist until arrested by the ligaments 
which unite it with the carpus, or by the capacity of the joint to admit 
of motion in this direction. When the lower end of the radius is 
broken, and the ligaments of the joint are more or less torn, the ulna, 

1 Velpeau, Boston Med. Journ., vol. xxxv. p. 213. 



284 FRACTURES OF THE RADIUS. 

although thrust downwards much farther perhaps than it could ever 
descend in its normal state, still fails to find a support, and spreading 
wider and wider from the radius as it is thrust further upon the hand, 
no limit can be given to its progress in this direction. It was thus 
that, in one example already mentioned, I found the ulna carried 
downwards one inch or more. 

The resistance will, then, in nearly all cases, be found to be in those 
ligaments which bind the lower fragment to the lower end of the ulna, 
and the ulna to the carpal bones, viz: the radio-ulnar, and the internal 
lateral ligaments, which in the normal state of the parts constitute the 
centre upon which forced adduction expends its power, and which 
still continue to be the point of resistance when the radius is broken. 
But how feeble and uncertain must be a resistance which depends 
solely on these injured ligaments! And how painful to the patient 
must be an extension sufficient to overcome the action of nearly all 
the muscles of the wrist, which is borne entirely by a few lacerated 
and inflamed fibres! even in health this position, when forced, cannot 
be endured beyond a few seconds, and it must be difficult to estimate 
the sufferings which the same position must occasion when the liga- 
ments are torn and inflamed. 

I am not to be told that surgeons have not intended to advocate this 
extreme practice; that they have never recommended forced adduc- 
tion but only a moderate and easy lateral inclination, such as can be 
comfortably borne. If they have not, then they should not have 
spoken of making extension by this means. An easy lateral inclina- 
tion has no power to do good so far as extension is concerned, any 
more than it has power do harm. But the fact is, while a majority 
of surgeons have no doubt used less force than was hurtful, some have 
used more than was useful or safe ; indeed, the sharpness of the curve 
given to the splints figured and recommended by Dupuytren, Nelaton, 
and others, sufficiently indicate that their distinguished inventors in- 
tended to accomplish by these means a forced and violent adduction. 

Malgaigne, speaking of other means of extension applied to the 
forearm, suggested by Godin, Diday, and Velpeau, intended to operate 
only in a straight line, and alluding especially to the modes devised 
by Huguier and Yelpeau, remarks : " Without discussing here, the 
comparative value of the two forms of apparatus, I believe that they 
could scarcely be endured by the patients ; and M. Diday tells us that 
in the trials which he has made, the pain produced by the extension 
was so great that he was compelled to renounce it." Which observa- 
tions cannot but apply equally to this plan of extension by adduction 
or to any other which might be adopted. 

After all, it must not be inferred that I have concluded to reject 
this mode of dressing in all of its modifications ; for although I am far 
from being persuaded of its utility as a means of extension and re- 
tention in any case, yet I am not prepared to deny it to some very 
considerable value in another point of view ; and when judiciously 
employed it can certainly do no harm. It is, I repeat, for another 
reason altogether than the one heretofore assigned, that I would re- 
commend its continuance, a reason which I cannot so well explain, or 



COLLES' FKACTUKE. 285 

hope to render intelligible, except to the practical surgeon. This 
position throws the whole lower end of both radius and ulna outwards 
toward the radial margin of the splints, and by keeping the radius 
more completely in view, it enables the surgeon better to judge of the 
accuracy of the reduction, and to recognize more readily the condition 
and situation of the compresses, etc. This alone I have always con- 
sidered a sufficient ground for retaining the angular splint; although 
I have treated a number of arms satisfactorily with the straight splints 
alone. 

Finally, while surgeons have been seeking to accomplish an indica- 
tion, the existence of which is at least rendered doubtful, and by means 
which appear to me totally inadequate, if it did exist, they have proba- 
bly too often overlooked or regarded indifferently an indication which 
is almost uniformly present, namely, to press forwards the tilted frag- 
ment by a force applied upon the wrist from behind, and to retain it 
in place by suitable compresses. And I cannot help thinking that if 
they had regarded this as the sole indication, an indication generally 
so easily accomplished, they would have made fewer crooked arms, 
and have saved their patients much suffering and themselves much 
trouble. Some of the cases which I have reported in the early part 
of this chapter, are intended to illustrate the value of this principle. 

It only remains for us to determine the precise form of splint which 
ought to be preferred', and to describe its mode of application. 

The narrow " attelle cubitale" of Dupuytren, is inconvenient ; nor 
can I give the preference to the curved dorsal splint recommended by 
Nekton, and employed by Eobert Smith, Erichsen, and others. It is 
not to me a matter of entire indifference, in case only one curved splint 
is employed, whether this be applied to the palmar or dorsal surfaces 
of the forearm. Foreign surgeons, so far as I know, have applied this 
splint to the dorsal surface, and the straight splint to the palmar; 
while American surgeons have adopted almost as uniformly the oppo- 
site rule — to whose practice, in this respect, I acknowledge myself 
also partial. It is to the curved splint rather than to the straight, 
that we mainly trust ; not simply, or at all, perhaps, because of its form, 
but because the curved splint is also the long splint. This is the 
splint, therefore, which ought to be the most steady and immovable 
in its position. !STow, the very irregularities of surface upon the 
palmar aspect of the forearm and hand, instead of constituting an 
embarrassment, enable us, when the splint is suitably prepared and 
adjusted, to fix it more securely. Moreover, upon it alone, after a 
few days, the surgeon may see fit to rely, and in that case it ought to 
be applied to that surface of the arm which is most tolerant of con- 
tinued pressure. The palmar surface, as being more muscular, and 
as having been more accustomed to friction and to pressure, must 
necessarily have the advantage in this respect. The palmar splint ter- 
minating also at the metacarpophalangeal articulations, instead of at 
the wrist, as the short straight splint must do when the hand is ad- 
ducted, enables the hand to be flexed upon its extremity over a hand- 
block, or pad of proper size. Such are the not insignificant advantages 




286 FRACTURES OF THE RADIUS. 

which we claim for this mode, over that pursued by our transatlantic 
brethren. 

The block suggested first by Bond, of Philadelphia, is a valuable 
addition ; since the flexed position is always more easy for the fingers, 
and in case of anchylosis this position renders the whole hand more 
useful. 

For myself, I am in the habit of preparing extemporaneously a splint 
from a wooden shingle, which I first cut into the requisite shape 
and length ; the length being obtained by measuring from the front 
of the elbow-joint, when the arm is flexed to a right angle, to the 
metacarpo-phalangeal articulations. It ought, indeed, to fall half an 
inch short of the bend of the elbow, to render it certain that it shall 
make no uncomfortable pressure at this point ; and the direction to 
measure with the arm flexed, is of sufficient importance to warrant a 

repetition. The breadth of the splint 
Fig. 86. should be in all its extent just equal 

to the breadth of the forearm in its 
widest part, so that there shall be no 
lateral pressure upon the bones. If 
the splint is of unequal breadth, the 
roller cannot be so neatly applied, and 
The author's splint. it is more likely to become disarranged. 

Thus constructed it is to be covered 
with a sack of cotton cloth, made to fit tightly, with the seam along 
its back ; and afterwards stuffed with cotton batting or with curled 
hair. These materials may be passed in, and easily adjusted, wherever 
they are most needed, from the open extremities of the sack. While 
preparing, the splint must be occasionally applied to the arm until it 
fits accurately every part of the forearm and hand, only that the stuf- 
fing must be rather more firm a little above the lower end of the 
upper fragment. The open ends of the sack are then to be neatly 
stitched over the ends of the splint, after which the splint may be laid 
directly upon the skin without any intermediate compresses or rollers. 
The advantages of this form of splint are easily comprehended. 
They consist in facility and cheapness of construction, accuracy of 
adaptation, neatness, permanency and fitness to the ends proposed. 

The extemporaneous splint recommended by Dr. Isaac Hays, of 
Philadelphia, is very similar, but it lacks the neatness and perma- 
nency of that which I have now described. 

In all cases it is better to employ, also, at least during the first fort- 
night, a straight dorsal splint, of the same breadth as the palmar splint, 
and of sufficient length to extend from the elbow to the middle of the 
carpus. This should be covered and stuffed in the same manner as 
the palmar splint, except that here the thickest and firmest part of 
the splint must be opposite the carpus and the lower end of the lower 
fragment. It will answer the indications also a little more completely 
if, at this point, the padding is thicker on the radial than on the ulnar 
side. 

Having restored the fragment to place, in case of Colles' fracture, 



FRACTUEES OF THE RADIUS. 



287 




by pressing forcibly upon the back of the lower fragment, the force 

being applied near the styloid apophysis of the radius, the arm is to 

be flexed upon the body, and 

placed in a position of semi-pro- Fig. 87. 

nation ; when the splints are to 

be applied, and secured with a 

sufficient number of turns of the 

roller, taking especial care not to 

include the thumb, the forcible 

confinement of which is always 

painful, and never useful. 

I cannot too severely reprobate 
the practice of violent extension 
of the wrist in the efforts at re- 
duction when no overlapping of 
the fragments exist, and that, 
whether this extension be applied 
in a straight line, or with the hand 
adducted. It has been shown 
that in a great majority of cases 
no indication in this direction is 
to be accomplished, and to pull 
violently under these circum- 
stances upon the wrist is not only 
useless but hurtful. It is adding 
to the fracture and to the other 
injuries already received, the 
graver pathological lesion of a 
stretching, a sprain of all the lig- 
aments connected with the joint. 
I am persuaded that to this violence, added to the unequal and too 
firm pressure of the splints, are, in a great measure, to be attributed 
the subsequent inflammation and anchylosis, in very many cases. 

The first application of the bandages ought to be only moderately 
tight, and as the inflammation and swelling develop in these struc- 
tures with rapidity the bandages should be attentively watched, and 
loosened as soon as they become painful. It must be constantly borne 
in mind that, to prevent and control inflammation, in this fracture, is 
the most difficult and by far the most important object to be accom- 
plished, while to retain the fragments in place, when once reduced, is 
comparatively easy and unimportant. 

During the first seven or ten days, therefore, these cases demand 
the most assiduous attention ; and we had much better dispense with 
the splints entirely than to retain them at the risk of increasing the 
inflammatory action. Indeed, I have no doubt that very many cases 
would come to a successful termination without splints, if only the 
hand and arm were kept perfectly still in a suitable position until 
bony union was effected. 

I must also enter my protest against many or all of those carved 
splints which are manufactured, hawked about the country, and sold 



The author's dressing complete. The curved 
palmar splint is not in view, only the dorsal. The 
faint white lines represent the roller. The sling is 
omitted for the purpose of bringing the other dress- 
ings into view. 



288 FRACTURES OF THE RADIUS. 

by mechanics, who are not surgeons ; with a fossa for each styloid 
process, a ridge to press between the bones, and various other curious 
provisions for supposed necessities, but which never find in any arm 
their exact counterparts, and only deceive the inexperienced surgeon 
into neglect of the proper means for making a suitable adaptation. 
They are the fruitful sources of excoriations, ulcerations, inflamma- 
tions, and deformities. 

In reference to the treatment of these fractures, the following cases 
and the accompanying remarks, by that great surgeon Dupuytren, are 
too pertinent not to merit a place in every treatise of this character. 

" The two succeeding cases are not only interesting as fractures of 
the radius, but they are further deserving of attentive consideration 
on account of the serious complications which accompanied them, and 
which were the consequence of forgetting an important precept. More 
than once, indeed, it has occurred that the surgeons have been so in- 
tent on preserving fractures in their proper position that the extreme 
constriction employed has actually caused destruction of the soft parts. 
A piece of advice which I have very frequently given, and which I 
cannot too often repeat is, to avoid tightening too much the apparatus 
for fractures during the first few days of its being worn ; for the swell- 
ing which supervenes is always accompanied by considerable pain, 
and may be followed by gangrene. It cannot therefore be too urgently 
impressed on young practitioners, to pay attention to the complaints 
which patients make ; and to visit them twice daily, and relax the 
bandages and straps as need may be, in order to obviate the frightful 
consequences which may spring from not heeding this necessary pre- 
caution : by carefully attending to this point I have been saved the 
painful alternative of ever having to sacrifice a limb for complications 
which its neglect may entail. 

"Antoine Eilard, set. 44, fractured his right radius whilst going 
down into a cellar, in Feb. 1828, and went at once to the Hospital 
of La Charite. When the fracture was reduced (it was near the base 
of the bone) an' apparatus was applied, but fastened too tightly; and, 
notwithstanding the great swelling and the acute pain which the 
patient endured, it was not removed until the fourth day, when the 
hand was cold and oedematous, and the forearm red, painful, and 
covered with vesications. Leeches, poultices, and fomentations were 
applied, and followed by some alleviation of the local symptoms, 
though there was much constitutional disturbance. At the close of a 
fortnight from the accident, the palmar surface of the forearm pre- 
sented a point where fluctuation was supposed to exist ; but when a 
bistoury was plunged into it no matter followed. Portions of the 
flexor muscles subsequently sloughed, and the skin subsequently 
mortified. The only resource was amputation, which was performed 
above the elbow six weeks after his admission ; and he afterwards 
recovered without the occurrence of any further untoward symptoms. 

"K., aet. 36, was at work boring an artesian well in 1832, when he- 
was struck by part of the machinery on the right forearm ; he was 
instantly knocked down and thrown violently on the right thigh. A 
surgeon who was sent for detected a fracture of the radius, and ap- 






FRACTURES OF THE RADIUS. 289 

plied the usual apparatus, consisting of pads and splints, confined by 
a roller extending from the extremities of the fingers to the elbow, 
which compressed the arm so tightly as to give rise to very great 
suffering. The fingers, hand, and forearm were numbed almost to 
insensibility, and yet the surgeon in attendance did not think proper 
to loosen the apparatus. Such was the condition of the patient until 
he came to the Hotel Dieu, four days after the accident; the fingers 
were then black, cold, and insensible, and when I removed the splints 
I found the hand likewise black, especially on its palmar surface. The 
lower part of the forearm was a shade less livid, but equally cold and 
insensible; and several vesicles filled with pink colored serum were 
apparent on both its surfaces where the splints had pressed; the upper 
part of the forearm was inflamed, swollen, and very painful. He was 
bled and leeches were applied to the inflamed part of the arm ; cam- 
phorated spirit was applied to the fingers. 

* On the following day heat was restored as low as the wrist, but 
the hand remained for the most part livid and cold, and the radial 
artery did not pulsate. Seventy leeches were applied to the forearm, 
and the local application was continued." On the second day after 
admission thirty more leeches were applied. On the fourth day the 
hand looked a little better, so as to " encourage some hope of its being 
saved; but this was again blighted on the sixth day, by the entire loss 
of heat and sensibility in the part and increased pain and swelling in 
the forearm, to which the gangrene subsequently extended. On the 
twelfth day amputation was performed at the elbow-joint; but the 
patient did not survive the operation more than ten days, the immedi- 
ate cause of death being acute pleurisy. There was a considerable 
quantity of purulent serosity poured out on the right side of the chest ; 
and abscesses were found in the lungs and liver. On examining the 
arm, there was found to be a simple fracture of the radius about its 
centre. 

"The above case presents a painful illustration of the neglect to 
which I have alluded. In nearly every instance the swelling of the 
limb requires that careful attention should be paid to the bandage or 
straps, by which the apparatus is confined. Similar accidents are 
likely to result from the employment of an immovable apparatus, of 
which an example occurred in the practice of M. Thierry, one of my 
pupils. He was summoned to visit a young girl, on whom such an 
apparatus had been applied for supposed fracture of the radius. 
After suffering excruciating torment, the forearm mortified, and am- 
putation was the only resource ; on examining the limb no trace of 
fracture could be discovered. Had a simple apparatus been here em- 
ployed, and properly watched, this patient's limb would not have been 
sacrificed." 1 

Eobert Smith mentions, also, the case of a boy, aet. 18, who had a 
fracture of the lower extremity of the radius, through the line of the 
junction of the epiphysis with the diaphysis, caused by being thrown 
from a horse. A surgeon applied, within an hour, a narrow roller 

1 Dupuytren, Injuries and Diseases of Bones, Syd. ed., London, 1847, pp. 1-45-7. 



290 FRACTURES OF THE RADIUS. 

tightly around the wrist. On the following day the limb was in- 
tensely painful, cold and discolored ; still the roller was not removed, 
nor even slackened. On the fourth day he was admitted into the 
Richmond Hospital, when the gangrene had reached the forearm. 
Spontaneous separation of the soft parts finally occurred, and the 
bones were sawn through twenty-four days after the fracture was 
produced, from which time "everything proceeded favorably." 1 

Nov. 21, 1851, a boy, ten years old, living in the town of Andover, 
Mass., had his left hand drawn into the picker of a woollen mill, pro- 
ducing several severe wounds of the hand and a fracture of the radius 
near its middle. One of the wounds was situated directly over the 
point of fracture, but whether it communicated with the bone or not 
was not ascertained. A surgeon was called, who closed the wounds, 
covered the forearm with a bandage from the hand to above the elbow, 
and applied compresses and splints. This lad made no complaint, his 
appetite remaining good and his sleep continuing undisturbed, until 
the third day, when he began to speak of a pain in his shoulder ; on 
the same day also it was noticed that his hand was rather insensible to 
the prick of a pin. Early on the morning of the fourth day his sur- 
geon being summoned, found him suffering more pain and quite rest- 
less ; and on removing the dressings, the arm was discovered to be 
insensible and actually mortified from the shoulder downwards. 

Opiates and cordials were immediately given to sustain the patient, 
and fomentations ordered. 

On the sixth day a line of demarcation commenced across the shoul- 
der, and on the twenty-first day, the father himself removed the arm 
from the body by merely separating the dead tissues with a feather. 
Subsequently a surgeon found the head of the humerus remaining in 
the socket, and removed it, the epiphysis having become separated 
from the diaphysis. The boy now rapidly got well. 

In the year 1853, this case became the subject of a legal investiga- 
tion, in the course of which Dr. Pilsbury, of Lowell, Mass., declared 
that in his opinion this unfortunate result had been caused by too 
tight bandaging, and by neglecting to examine the arm during four 
days. 

On the other hand, Drs. Hay ward, Bigelow, Townsend, and Ains- 
worth, of Boston, with Kimball, of Lowell, Drs. Loring, and Pierce, 
of Salem, believed that the death of the limb was due to some injury 
done to the artery near the shoulder -joint ; and in no other way could 
they explain the total absence of pain during the first two days ; nor 
could they regard this condition as consistent with the supposition 
that the bandage occasioned the death of the limb. 2 

I cannot but think, however, that these gentlemen were mistaken, 
and that the gangrene was alone due to the bandages. In a similar 
case which came under my own observation, and in which both the 
radius and ulna were broken, the roller extended no higher than just 
above the elbow, and the patient complained of no pain until the 

1 R. Smith, Treatise on Fractures, &c, Dublin, 1854, p. 170. 

2 Bost. Med. and Surg. Journ., vol. xlviii. p. 281. 



FEACTUEES OF THE EADIUS. 291 

bandages were unloosed, yet the arm separated at the shoulder-joint. 
I shall refer again to this example in the chapter on fractures of the 
radius and ulna ; and I shall take occasion then also to speak more 
fully of the causes of these terrible accidents. 

Norris mentions another case of compound fracture of the lower 
end of the radius which came under his notice at the Pennsylvania 
Hospital in August, 1837, the arm having been dressed by a surgeon 
within half an hour after the accident, with bandages and splints. 
When these bandages were removed at the hospital, on the fifth day, 
''the soft parts around the fracture were found to have sloughed, an 
abscess extended up to the elbow-joint, and sloughs existed over the 
condyle. Severe constitutional symptoms arose, making amputation 
of the arm necessary." 1 

A lady, aet. 50, was also seen by Thierry, who, having broken the 
radius near its lower end, lost her fingers by the sloughing consequent 
upon a tight bandage. 2 

A woman was admitted into one of Dr. Wood's wards in the Belle- 
vue Hospital about the first of Feb'y, 1863, who had fallen upon her 
hand a few days before and broken the radius just above the wrist. 
Her arm was dressed with splints and bandages at one of the dis- 
pensaries in this city. Gangrene ensued, and when I saw her on the 
8th of Feb'y the death had extended to the middle of the forearm ; 
the dead tissues being dry and black. Dr. Wood amputated the 
arm, but she died. 

The remarks which have now been made in relation to the treatment 
of Colles' fracture, are applicable, with only such slight modifications 
as would naturally be suggested, to fractures of the lower end of the 
radius commencing upon the radial side of the bone and extending 
obliquely downwards into the joint ; and it is to this form of fracture 
especially, that the pistol-shaped splint must be found applicable. If 
the fracture actually extends into the joint, it must not be forgotten 
that, in order to the prevention of anchylosis, the wrist should be 
early subjected to passive motion. 

The following example of a compound, comminuted fracture of the 
radius, may serve to illustrate the value of a somewhat novel mode 
of treatment under certain circumstances : — 

William Croak, of Buffalo, set. 30. Jan. 29, 1856, a large piece of 
iron casting fell upon his arm, crushing and lacerating the wrist, and 
comminuting the lower part of the radius ; he was immediately taken 
to the Hospital of the Sisters of Charity. I found the whole of the 
soft parts torn away in front of the joint, and the fragments of the 
radius projected into the flesh in every direction. The hope of saving 
the hand seemed to be scarcely sufficient to warrant the attempt; at 
least by the ordinary mode of procedure. I, however, stated to the 
gentlemen present, among whom were Dr. Rochester, my colleague, 
and the house surgeon, Dr. Lemon, that 1 believed it could be saved 
if, having removed the fragments of the radius, we practised resection 

1 Norris, note to Liston's Surgery, p. 54. 

2 Arner. Journ. Med. Sci., vol. xxv. p. 461, from L'Experience for 1S3S. 



292 



FEACTUEES OF THE RADIUS. 



Fig. 88. 



of the lower end of the ulna, and allowed the muscles to become com- 
pletely relaxed. Accordingly, after placing my patient under the 
influence of chloroform, I enlarged the wounds so as to enable me to 
remove six or seven fragments of the radius, leaving others which 
were broken off but not much displaced. I then removed with the 
saw one inch and a half of the lower end of the ulna. The hand was 
immediately drawn up by the contraction of the remaining muscles, 
but their tension was completely relieved. 

The wounds were closed and dressed lightly, and the whole limb 
was placed on a broad and well-padded splint covered with oiled cloth. 
The hand, which was very pale and exsanguine, was covered with 
warm cotton batting. 

The subsequent treatment was changed from time to time to suit 
the indications ; but his recovery was rapid and complete, nor was 
there at any time excessive inflammation in any part of the limb. 

I have seen this man frequently since he left the hospital, and while 
he has recovered only a little motion in the wrist-joint, his hand and 
fingers are nearly as useful as before the accident. He is 
able to perform all ordinary kinds of labor with almost as 
much ease as most other men ; and what is always grati- 
fying to the humane surgeon, he does not fail to appre- 
ciate fully the service which has been conferred upon him 
by the preservation of his somewhat mutilated hand. 

I have recently adopted the same treatment with equal 
success in a case of gunshot wound of the lower end of 
the radius. 

Epiphyseal Separations. — This bone is formed from 
three centres, namely, one for the shaft and one for either 
extremity. The shaft is ossified at birth. About the end 
of the second year ossification commences in the lower 
epiphysis, and it becomes united to the shaft at about the 
twentieth year. The same process commences in the 
upper epiphysis at about the fifth year, and is completed 
by consolidation with the shaft at the age of puberty. 

I have met with no recorded examples of separation of 
the upper epiphysis, and the examples of separation of 
the lower epiphysis have seldom been clearly made out. 
I have already mentioned one as having been reported by 
Robert Smith. He speaks also of other cases occurring 
in conjunction with a separation of the lower end of the 
ulna, and which is very liable to be mistaken for a dis- 
location. 1 

The treatment of this accident will not require any 
special consideration, since it will not differ essentially from the treat- 
ment required in a fracture occurring at the same point. 



Radius, with 

epiphyses. 

(From Gray.) 



1 Robert Smith, op. cit., p. 164. 



SHAFT OF THE ULNA. 



293 



CHAPTEE XXII. 



FRACTURES OF THE ULNA. 



§ 1. Shaft of the Ulna. 



Causes. — The shaft of the ulna is generally broken by a direct blow. 
I have never seen an exception to this rule ; but Yoisin has related in 
the Gazette Medicate for 1833, a single exception in which it was said 
to have been broken by a fall upon the palm of the hand. Malgaigne 
thinks it is most often broken when one seeks to ward off a blow with 
the arm ; but it has happened most often to me to see it broken by a 
fall upon the side of the arm. 

Point of Fracture, Direction of Displacement, &c. — In an analysis 
of thirty-three cases, I find the shaft has been broken eleven times in 
its upper third, twelve times in its middle third, and ten 
times in its lower third. All portions seem, therefore, p iff 89> 
to be about equally liable to fracture. I think, also, the 
fractures have generally been oblique. 

Contrary to what has been observed by other writers, 
I have noticed that no law prevailed as to the direction 
in which the fragments have become displaced ; the 
broken ends being found directed forwards, backwards, 
inwards, or outwards, according to the direction of the 
blow which has occasioned the fracture ; and this is in 
accordance with the general rule in other fractures 
occasioned by direct blows. No doubt, however, other 
things being equal, the tendency of the lower fragment 
would be toward the interosseous space, in consequence 
of the action of the pronator quadratus in this direction, 
while the upper fragment, owing to its broad and firm 
articulation at the elbow-joint, can only be displaced 
forwards or backwards, at least to any great extent. 

Complications. — In no case of the shaft of a long bone 
have I found serious complications more frequent than 
in fractures of the shaft of the ulna. Four have been 
compound ; eleven complicated with a forward, or for- 
ward and outward dislocation of the head of the radius ; 
one with a partial dislocation of the lower end of the 
radius backwards, and one with a dislocation of both 
radius and ulna backwards at the elbow-joint. It will be seen, there- 
fore, that sixteen, or nearly one-half of the whole number, have been 
seriously complicated. 

Symptoms. — Occasionally this fracture is found to exist without 
sensible displacement. In such cases the diagnosis is sometimes ditri- 



Fracture of the 

shaft of the ulna. 



294 FKACTUEES OF THE ULNA. 

cult, and can only be determined by the crepitus and mobility. If, 
however, the ulna is firmly seized above and below the point which 
has suffered contusion, and pressed in opposite directions, these signs 
will generally be sufficiently manifest, and will render the diagnosis 
certain. 

But in cases where there is considerable displacement, the inner 
surface of the bone is so superficial as to enable us to detect its devia- 
tions with the eye alone, or, when swelling has already occurred, by 
the fingers carried firmly and slowly along this margin. 

If the head of the radius is dislocated also, the displacement of the 
broken ends of the ulna must always be considerable, and the con- 
sequent deformity palpable. I have known one instance, however, 
in which a surgeon living in the neighboring Province of Upper 
Canada, recognized and reduced a dislocation of the radius and ulna 
backwards, but did not detect a fracture of the ulna two inches above 
its lower end. Six months after, in the month of March, 1856, the 
patient called upon me with a marked deformity near the wrist, oc- 
casioned by the backward projection of the broken ulna, and with a 
complete loss of the power of supination. It will not surprise us that 
this fracture was overlooked when we learn that the man had fallen 
fifty-five feet. 

Prognosis. — In simple fractures the prognosis is generally favorable, 
since no overlapping can occur, and the lateral displacements are not 
usually sufficient to produce a marked deformity, or to interfere 
materially with the functions of the arm ; yet it is not unfrequent to 
find the fragments inclining slightly forwards or backwards, inwards 
or outwards. If the fragments fall toward the radius, I have noticed 
in three or four instances a slight projection of the lower end or sty- 
loid process of the ulna to the ulnar side ; but not interfering in any 
degree with the motions of the wrist-joint. 

I have seen the radius left unreduced seven times after a fracture of 
the ulna, and in each example the forearm was shortened. A boy, set. 
17, was struck by a locomotive, and severely injured in various parts 
of his body, June 5, 1855. I saw him with two very intelligent coun- 
try practitioners, a few hours after the accident. The whole left arm 
was then greatly swollen. Crepitus was distinct, and we easily recog- 
nized the fracture of the ulna about three inches below its upper end, 
with which an open wound was in direct communication. We sus- 
pected, also, a dislocation of the head of the radius forwards, but as we 
could not make ourselves certain, and finding that the arm was in 
such a condition as to preclude any further manipulation without 
greatly diminishing the chance of saving the limb, we made no attempt 
at reduction, but laid the arm upon a pillow and directed cool water 
lotions. 

At no subsequent period, in the opinion of the medical gentleman 
who was left in charge, did a favorable opportunity occur to reduce 
the radius ; and at the end of two months I found the ulna united, 
with the fragments bent forwards and outwards toward the radius, 
while the head of the radius lay in front of the humerus. The forearm 
was shortened three-quarters of an inch. He could flex his arm freely 



SHAFT OF THE ULNA. 295 

to a right angle and a little beyond ; and he could straighten it per- 
fectly. Hand slightly prouated, with partial loss of supination. Whole 
arm nearly as strong and as useful as before the accident. 

The second case occurred in the person of a man aet. 26, residing 
about twenty miles from town, and was occasioned by the kick of a 
horse. This was also a compound fracture. It does not appear that 
his surgeon discovered the dislocation of the radius, but supposed that 
it was a fracture of both bones. On the ninth day the patient became 
dissatisfied and dismissed his surgeon, but employed no other. 

Oct. 1, 1849, eleven weeks after the accident, he called upon me. I 
found the ulna united with a manifest displacement, but I could not 
discover that there had been any fracture of the radius. The head 
of the radius was in front of the external condyle, and a depression 
existed where it formerly articulated. When the arm was flexed, the 
head did not strike the humerus so as to arrest the flexion, but it 
glided upwards and outwards along the inclined base of the external 
condyle. He had already begun to use his arm considerably in labor. 
The forearm was shortened one inch. 

I found the ulna much bent forwards a little below its middle, the 
head of the radius displaced forwards, and the forearm shortened one 
inch. 

Three times I have noticed after the lapse of several years that the 
forearm could not be perfectly supinated; but pronation was never 
permanently impaired. I think, also, that the motions of flexion and 
extension have always, except where the radius has remained dislo- 
cated, been completely restored soon after the splints were removed ; 
and even in these latter cases, it is only extreme flexion which has 
been hindered. 

Treatment. — In simple fracture we must look carefully to the lateral 
deviation of the fragments, and if they are found to be salient forwards 
or backwards, pressure made directly upon or near their extremities, 
restores them to place, but it often requires considerable force to ac- 
complish this. A gentleman fell and broke the right ulna near its 
middle. He came immediately to me, and I found the fragments dis- 
placed backwards. Pressing strongly with my fingers, they sprung 
forwards with a distinct crepitus, and I thought they were now in 
exact line. A broad and well-padded splint was applied to the fore- 
arm, and I took especial pains with compresses nicely adjusted, from 
day to day, to keep everything in place. The arm was placed in a 
sling. Eight months after the accident this gentleman died of cholera, 
and I was permitted to dissect the arm. I found the fragments well 
united, but with a very palpable projection of the fragments back- 
wards, in the direction in which they were at first. 

If the displacement is in the direction of the radius, it is more diffi- 
cult to overcome, but its necessity is much more urgent, since if the 
fragments fall completely against the radius, a bony union may take 
place, occasioning a complete loss of the power of pronation and of 
supination. 

While moderate extension is being made, and the hand is well 
supinated, the fingers of the surgeon should be pressed firmly, and in 






296 FRACTURES OF THE ULNA. 

spite sometimes of the complaints of the patient, between the radius 
and ulna, and the fragments of the broken ulna fairly pushed out from 
the radius. 

The forearm may now be laid in the usual position against the front 
of the chest, midway between supination and pronation, and the same 
splints applied and in the manner which we shall hereafter describe 
for fractures of the shaft of both bones. 

We ought, however, especially to bear in mind the danger of thrust- 
ing the fragments against the radius, by allowing the sling or the 
bandage to rest against the middle of the ulnar side of the bone. To 
prevent this, the sling ought to support the arm by passing only under 
the hand and wrist, or the forearm may be laid in a firm gutter w r hich 
will touch the forearm only at the elbow and wrist, or it may be laid 
upon its back as suggested and practised by Fleury, who, according 
to Malgaigne, had a case which had been treated in the position of 
semi-pronation, and which remained not only displaced but refused to 
unite ; but when the arm was supinated, the fragments came at once 
into contact and bony union speedily took place. This position may 
be adopted whenever it is found to be practicable; but the position of 
demi-pronation is generally much more comfortable to the patient, at 
least when the forearm is laid across the chest, and very few patients 
will submit to a position of complete supination. 

In fractures accompanied with dislocation of the head of the radius 
forwards or backwards, nothing should prevent the immediate reduc- 
tion of the dislocation but a demonstration of its impossibility, or a 
condition of the limb which would render manipulation hazardous. 
It can be reduced, generally, by pushing forcibly upon the head of the 
bone in the direction of the socket, while the arm is moderately flexed 
so as to relax the biceps, and while extension is being made at the 
forearm by an assistant. In making the counter-extension, care should 
be taken to seize the lower end of the humerus by the condyles, rather 
than by its anterior aspect, by which precaution we shall avoid press- 
ing upon and rendering tense the tendon of the biceps. 

July 29, 1845, a lad, set. 9, fell from his bed, breaking the ulna 
and dislocating the head of the radius. Dr. Austin Flint was called 
on the following morning, and at his request I was invited to see the 
patient with him. We found the ulna broken obliquely near its mid- 
dle, and the head of the radius dislocated forwards. While Dr. Flint 
seized the elbow in front of the condyles, I made extension from the 
hand, the forearm being slightly flexed upon the arm, and at the same 
moment I pushed forcibly the head of the radius back to its socket. 
The reduction was accomplished easily and completely. 

We then dressed the arm with Eose's angular splint, constructed 
with a joint opposite the elbow. This was laid upon the palmar sur- 
face, and the whole was nicely padded, especially in front of the head 
of the radius. In two weeks pasteboard was substituted for the angu- 
lar splint. At the end of six weeks I was permitted to examine the 
arm and found the head of the radius perfectly in place, but the points 
of fracture slightly salient. All of the motions of the arm were fully 
restored. 



CORONOID PROCESS OF THE ULNA. 297 

June 2, 1845. C. C, set. 9, fell upon his arm, breaking the ulna 
obliquely near its middle, and dislocating the head of the radius for- 
wards. Dr. J. P. White being called, requested me to visit the patient 
also with him. We found one of the broken fragments protruding 
through the skin, on the inside of the arm. 

AVith great ease, and by simply pressing. with considerable force 
upon the head of the radius, it was made to slide into its socket. The 
case was left in charge of Dr. White. 

Five weeks after, I found all of the motions of the forearm com- 
pletely restored, except that he could not extend it perfectly. The 
head of the radius was also a little more prominent in front than in 
the opposite arm. 

Four or five years afterwards, the projection of the head of the 
radius had disappeared, and the functions of the arm were perfect. 

The following example of compound and comminuted fracture of 
the ulna will illustrate how much may be accomplished by conserva- 
tive surgery : — 

A German lad, set. 10, was run over by a railroad car, Sept. 4, 1857. 
Drs. C. F. Gay and Austin Flint, Jr., were summoned immediately ; 
but the limb presented such a discouraging appearance as induced 
them to send for me also. 

We found the ulna very much broken near its lower end, and about 
two inches of it entirely gone. The radius was sound. The skin and 
muscles were extensively lacerated and torn off in shreds. 

After a careful examination, finding that the radial and ulnar arte- 
ries continued to pulsate, we agreed to attempt to save the limb. It 
was accordingly laid upon a board covered with a soft and nicely 
adjusted cushion ; such vessels as were bleeding were tied; the skin 
was loosely stitched together, and the whole covered with a cotton 
cloth smeared with simple cerate. Cool water dressings were directed, 
and the boy was left in charge of Drs. Gay and Flint. The skin sub- 
sequently sloughed extensively, and also more or less of the muscular 
tissue; but on the 1st of May, 1858, about eight months from the 
time of the accident, it had nearly or quite closed over, and although 
his arm was very much deformed and maimed, it was still very use- 
ful ; indeed, to one who must earn his living by his hands alone, its 
value is beyond estimate. 



§ 2. Coronoid Process of the Ulna. 

Dissections have established the possibility of this fracture as a 
simple accident in the living subject; but I have not mj'self seen any 
example of which I can speak positively. In the two following cases, 
the existence of such a fracture was at first suspected, but I have now 
very little doubt but that my diagnosis was incorrect. I shall relate 
them, however, as examples of those accidents which are likely to be 
mistaken for fracture of this process. 

A laboring man, aged about twenty-five years, had been seen and 
treated by another surgeon, for what was supposed to be a simple 
20 



298 FRACTURES OF THE ULXA. 

dislocation of the radius and ulna backwards. The surgeon thought 
he had reduced the dislocation very soon after the accident, On the 
following day he found the dislocation reproduced, and he requested 
me to see the patient with him. The arm was then much swollen, 
but the character of the dislocation was apparent. By moderate ex- 
tension, applied while the arm was slightly flexed, and continued for 
a few seconds, reduction was again effected ; the bones returning to 
their places with a distinct sensation; but on releasing the arm the dis- 
location was immediately reproduced. These attempts to reduce and 
retain in place the dislocated bones were repeated several times during 

Fig. 90. 



Fracture of the coronoid process. 

this day, and on subsequent days, but to no purpose, and the patient 
was dismissed after about two weeks with the bones unreduced. 

The impossibility of retaining the bones in place, and the existence 
of an occasional crepitus during the manipulation, inclined me to be- 
lieve at the time that the dislocation was accompanied with a fracture 
of the coronoid process. 

Another similar case has since presented itself in a child nine years 
old, and in which the subsequent examinations not only demonstrated 
the non-existence of a fracture, but also rendered doubtful the justness 
of the conclusions which I had drawn in the case just related. 

This lad fell, Nov. 4, 1855, and his parents immediately brought 
him to me ; but as he lived many miles from town, I did not see him 
until eighteen hours after the injury was received. I found the arm 
much swollen, slightly flexed and pronated. Flexion and extension of 
the arm were very painful ; the pain being referred chiefly to the front 
of the joint, near the situation of the coronoid process; and at this 
point also there was a discoloration of the size of a twenty-five cent 
piece. Flexing the forearm moderately upon the arm and making 
extension, the bones came readily into place, but without sensation of 
any kind, either a snap or a crepitus. That the bones had now re- 
sumed their position, however, I made certain by a very careful exami- 
nation with the hand and by measurement ; yet they would not remain 
in place one moment when the extension was discontinued. The 
reduction was made several times, and constantly with the same 
result. We then applied a right-angled splint to the arm, having first 
reduced the bones, and thus were able to retain them in position. I 
believed that the coronoid process was broken, and so informed the 
surgeon to whose care the boy was returned. 

Five months after, he was brought again to me, and I then found 
that the radius and ulna had been kept in place ; the motions of the 
joint were perfect, and if the coronoid process had ever been broken it 
was now again in its natural position, and with every structure about it 
in a condition as complete as it was before the accident. For myself, 



COEOXOID PROCESS OF THE ULNA. 299 

I do not believe that so perfect a union of this process can happen — at 
least in a case where, as must have been the fact in this example, the 
separation and displacement of the process are such that it no longer 
offers an obstacle to the dislocation of the ulna backwards and upwards. 

Malgaigne thinks that the fracture is more frequent than the small 
number of reported examples would lead us to suppose, especially 
because he has noticed how often the summit of the process is broken 
off) when dislocation of the radius and ulna backwards is produced 
artificially on the dead subject. In three or four cases, also, of dis- 
locations of these bones backwards and inwards, which had come 
under his notice, he was unable to feel this process, and he therefore 
thought it probable that it was broken off. Other surgeons have 
thought, also, that it was a not infrequent accident; and they have 
constantly made use of this supposition to explain those cases .in 
which, the radius and ulna having been dislocated backwards, would 
not afterward remain in place when well reduced. Fergusson has 
indeed made the extraordinary statement in relation to dislocations of 
the radius and ulna backwards generally, that in these cases " the 
coronoid process will probably be broken." 

But, in my opinion, these fractures are exceedingly rare; and I think 
these gentlemen need to have furnished some more conclusive evi- 
dence of the correctness of their opinions, than can be found in their 
writings, or in the writings of any other surgeons which I have seen. 

Malgaigne mentions three reported examples, namely: one pub- 
lished by Combes Brassard, an Italian surgeon, in 1811, which Bras- 
sard saw only after a lapse of three months ; one seen by Penneck, and 
published in the Lancet in 1828, the patient then being sixty years 
old and the accident having occurred while he was a young man ; the 
third was seen by Sir Astley Cooper, several months after the accident, 
and is reported by himself in his excellent treatise on Fractures and 
Dislocations. Says Mr. Cooper : " It was thought, at the consultation 
which was held about him in London, that the coronoid process was 
detached from the ulna." This was the only living example seen by 
Mr. Cooper in his long and immensely varied surgical practice ; and 
even here we cannot fail to notice the apparent reserve with which he 
expresses his opinion — " It was thought at the consultation." 

To these examples our own researches have added a few others. 

Dorsey says that Dr. Physick once saw a fracture of the coronoid 
process. The symptoms resembled a luxation of the forearm back- 
wards, " except that when the reduction was effected, the dislocation 
was repeated, and by careful examination, crepitation was discovered. 
The forearm was kept flexed at a right angle with the humerus. The 
tendency of the brachieus internus to draw up the superior fragment 
was counteracted in some measure by the pressure of the roller above 
the elbow. A perfect cure was readily obtained." 1 In 1830, Dr. Win. 
M. Fahnestock reported a case occurring in a boy, who, having fallen 
from a haymow, received the whole weight of his body " on the back 
part of the palm of the left hand," while the arm was extended for- 

1 Dorsey, Elements of Surgery, vol. i. p. 152. Philadelphia, 1S13. 



300 FRACTURES OF THE ULNA. 

wards. It seemed to be a dislocation of the forearm backwards, but 
when reduced it was again immediately displaced, with an evident 
crepitus. The arm was secured in the angular splint of Dr. Pkysick, 
and "recovered very speedily." 1 Dr. Couper, of the Glasgow Infirm- 
ary, also has reported a dislocation of the forearm backwards and out- 
wards, occurring in a young man aged seventeen, and which he thinks 
was accompanied with this fracture. The dislocation was easily re- 
duced, but returned again immediately on ceasing the extension. The 
fragment was not felt, nor does he speak of crepitus; the existence of 
the fracture being inferred from the fact that the bones would not 
remain in place without help. The forearm was placed across the 
chest, with the fingers pointing toward the opposite shoulder, and 
secured in this position with splints and a bandage. At the end of 
four weeks union had taken place, with only slight deformity, although 
with some stiffness of the joint. 

In relation to this example, the editor remarks that the symptoms 
were not to his mind conclusive in determining the existence of a 
fracture of the coronoid process, and he inclines to the belief that it 
was rather an oblique fracture of the lower extremity of the humerus. 
"In cases like these," he adds, "where very rare accidents are suspected, 
we think that unless the diagnosis is clear, the leaning should always 
be the other way : we mean, that, cseteris paribus, the symptoms should 
rather be referred to the common than the extraordinary injury. The 
contrary practice introduces a dangerous laxity in diagnosis." 2 

Dr. Duer, of Philadelphia, has reported a case which occurred in a 
boy six years old, and in which he felt and moved the fragment with 
his fingers. It was complicated with a dislocation, which remains un- 
reduced. This case was last seen about seven weeks after the accident. 3 
If at a later period we could be permitted to examine the patient, it is 
probable that the diagnosis might be rendered certain. 

In the American Medical Monthly for October, 1855, also, I find the 
report of a trial for malpractice, in which a lad nine years old received 
some injury about the elbow-joint which resulted in a maiming. The 
defendant claimed that there had been a dislocation of the forearm 
backw r ards, accompanied either with a fracture of the trochlea of the 
humerus, or of the coronoid process of the ulna. 

Dr. Crosby, of Dartmouth College, testified that he had never met 
with a fracture of this process, yet he would not say that it did not 
exist in this case. He w r as not able to decide positively. Dr. Peaslee, 
of the same college, thought it altogether probable that it had been 
broken, and Dr. Spaulding was of the opinion fully that it had been 
broken. 

The jury did not agree, and a nonsuit was finally allowed by the 
court. 

The defendant, in his report of the trial, seems to me to have justly 
complained that Mr. Fergusson has said, that in a dislocation of the 
forearm backwards " the coronoid process will probably be broken." 

1 Fahnestock, Amer. Jonrn. Med. Sci., vol. vi. p. 267. 

2 Couper. Loud. Med.-Chir. Rev., new ?er., vol. xi. p. 509. 

3 Duer, Amer. Jouru. Med. Sci., Oct. lbt>3, p. 390. 



CORONOID PROCESS OF THE ULNA. 



301 



Fig. 91. 



This was urged in the trial by the plaintiff's counsel as contradictiug 
the medical testimony, and as evidence of a conspiracy on the part of 
the surgeons to defeat the ends of justice ; since they constantly affirmed 
that the accident was so rare as not to have been reasonably expected, 
and that a failure to look for or to discover it did not imply a lack of 
ordinary skill or care. 1 

Says Mr. Liston : " The coronoid process is occasionally pulled or 
pushed off from the shaft, more especially in young subjects. I saw 
a case of it lately, in which the injury arose in consequence of the 
patient, a boy of eight years, having hung for a long time from the 
top of a wall by one hand, afraid- to drop down ;" 2 after whom, Miller, 
Erichsen, Skey, Lonsdale, and most of the Scotch and English sur- 
geons have repeated the assertion that this process may be broken in 
this manner by the action of the brachialis anticus alone, yet no one 
of them has to this day seen another example. 

The explanation of the accident in the case of the boy, given by 
Liston, implies two anatomical errors : first, that the coronoid process 
is an epiphysis during childhood ; and second, that the bra- 
chialis anticus is inserted upon its summit. The coronoid 
process is never an epiphysis, but is formed from a com- 
mon point of ossification with the shaft; the olecranon 
process and the lower extremity of the ulna having also 
separate points of ossification : the olecranon becoming 
united to the shaft at the sixteenth year, and the lower 
epiphysis at the twentieth. Moreover, the brachialis an- 
ticus has its insertion at the base of the process and partly 
upon the body of the ulna, but in no part upon its sum- 
mit; indeed, the process seems rather to be intended as a 
pulley over which the brachialis anticus may play ; re- 
sembling also somewhat, in its function, the patella ; serv- 
ing to protect the joint and perhaps the muscle itself from 
becoming compressed in the motions of the joint. Cer- 
tainly it could never have been broken by the action of 
this muscle, and the case mentioned by Mr. Liston must 
find some other explanation. It may have been a rupture 
of the brachialis anticus itself, or of the biceps, or pos- 
sibly a forward luxation of the head of the radius. Either 
of these suppositions is more rational than the statement 
made by Mr. Liston, because either one of them is possi- 
ble, while his supposition is impossible. 

These, if I except my own, constitute all of the supposed 
examples seen in the living subject, of which I find any tJlna ' wi(h 
record ; nine in all. ' °£om7ra y ) 

The first two were not entirely satisfactory to Malgaigne ; 
the third is spoken of cautiously by Sir Astley Cooper, as if it needed, 
in addition to his own great name, the indorsement of the "London 
council." Dorsey reports his case upon hearsay, and the result is quite 
too satisfactory to give it much claim to credibility. Fahnestock's case 



Op. cit., vol. iv. p. 339. 



2 Liston, Practical Surgery, p. 55. 



302 FRACTURES OF THE ULNA. 

is to our mind far from being fully proven. Couper's case is doubted 
by Dr. Johnson ; and the New Hampshire case was not made out 
satisfactorily to either the jury or the medical men. Liston's case 
was simply impossible. Duer's case could have been better verified 
at a later period. 

Certainly it is not upon such testimony as this that we can rely to 
sustain Mr. Fergusson's opinion that it is likely to occur in all dislo- 
cations of the forearm backwards, or of Malgaigne's conjecture that 
it is of more frequent occurrence than the published cases would seem 
to show. Nor will it be regarded as conclusive, that the beak of the 
process is often found broken after luxations made upon the subject ; 
since between luxations thus produced, and luxations occurring in the 
living subject there exists this important difference : that in the case 
of the latter, muscular action is the principal agent in the production 
of the dislocation, while in the former it is the external force alone 
which drives the bone from its socket. 

The fact, therefore, that so few cases have ever been reported, and 
that most of these are far from having been clearly made out, remains 
presumptive evidence that the actual cases are exceedingly rare; but 
if to this we add such negative evidence as is furnished by actual dis- 
sections, and by examinations of the pathological cabinets of the 
world, we think the testimony is almost conclusive. 

Only four specimens have been mentioned by any of the surgical 
writers known to me. Sir Astley Cooper says that a person was 
brought to the dissecting room at St. Thomas's Hospital, who had been 
the subject of this accident. " The coronoid process, which had been 
broken off' within the joint, had united by a ligament only, so as to 
move readily upon the ulna, and thus alter the sigmoid cavity of the 
ulna so much as to allow in extension that bone to glide backwards 
upon the condyles of the humerus." 1 Mr. Bransby Cooper adds in a 
note that the external condyle of the humerus was also broken and 
united by ligament. 

Samuel Cooper describes, rather obscurely, a specimen contained in 
the University College Museum, "in which the ulna is broken at the 
elbow, the posterior fragment being displaced backwards by the action 
of the triceps; the coronoid process is broken off; the upper head of 
the radius is also dislocated from the lesser sigmoid cavity of the 
ulna, and drawn upwards by the action of the biceps. In this com- 
plicated accident, the ulna is broken in two places." 

Malgaigne says that Velpeau has also established by an autopsy the 
existence of a fracture of the coronoid apophysis, but without having 
given any further particulars in relation to the case. 

In addition to these examples, Charles Gibson, of Eichmond, Ya., 
has stated to me, by letter, that he has in his possession a specimen of 
this fracture, evidently belonging to an adult. The process was broken 
transversely near its extremity, and has united again quite closely and 
without any displacement, and without ensheathing callus. 

We must subject these specimens to analysis also. The first two 

1 A. Cooper, Dislocations and Fractures, p. 411. 



COROXOID PROCESS OF THE ULNA. 303 

were complicated with, other fractures, and the second, especially, 
seems to have been a general crushing of all the bones concerned in 
the formation of the elbow-joint : neither of them could have been 
occasioned by contractions of the brachialis anticus, while only that 
one described by Sir Astley Cooper could have been the result of a 
dislocation of the forearm backwards. Of the specimen said to have 
been seen by Yelpeau, I am unable to speak without more circum- 
stantial knowledge of its condition. Nor can I speak very confidently 
of that belonging to my distinguished friend, Dr. Gibson, of Virginia. 
Notwithstanding the respect which I entertain for his opinion, I can- 
not avoid a suspicion that the bone was never broken at all, since I 
find it more easy to believe that he is deceived by certain appearances, 
than that it should have united by bone again, and so perfectly as not 
to leave any line of separation or degree of displacement. Certainly 
the fracture was too high to have been produced by the action of the 
muscle, if such a thing were ever possible ; and if broken by a dislo- 
cation, which must have forced it violently from its position, as the 
ulna was driven upwards, it is to me incredible that it should ever be 
made to unite again so perfectly. 

We are therefore left as before, with no evidence that the coronoid 
process was ever broken by the action of a muscle, and with only one 
example in which it is probable that a fracture occurred as a conse- 
quence of a dislocation of the radius and ulna backwards. If then it 
does happen that in this dislocation it is pretty often found difficult 
or impossible to retain the bones in place without aid, it will be the 
part of prudence to ascribe this troublesome circumstance to some 
more common accident than a fracture of the coronoid process : per- 
haps to a fracture of some portion of the lower end of the humerus, 
or to a disruption, more or less complete, of the tendons of the biceps 
and brachialis anticus, together with the ligaments which surround 
the joint. 

Causes. — It is probable that this process will be sometimes broken 
in a fall upon the palm of the hand; the force of the blow being 
received directly upon the lower end of the radius, and, through its 
numerous muscles and ligamentous attachments, being indirectly con- 
veyed to the ulna, producing a violent concussion of the coronoid 
process against the trochlea of the humerus, and resulting finally in 
a fracture of this process and a dislocation of both bones of the fore- 
arm backwards. The gentleman seen by Sir Astley had fallen upon 
his extended hand while in the act of running. Brassard's patient 
had fallen also upon his hand with his arm extended in. front. Pen- 
neck's patient, an old man of sixty years, had fallen upon the palm of 
his hand, and Fahnestock's fell upon the "back of the palm." In no 
other case is the point upon which the blow was received particularly 
mentioned. In two of the examples mentioned by Malgaigue there 
was a luxation of the forearm backwards ; such was also the fact in 
the case seen by Fahnestock ; in Couper's case it was dislocated back- 
wards and outwards, and in Sir Astley's case I infer that there was 
only a subluxation of the ulna backwards. 

We know of no other causes, therefore, than such as equally tend 



301 FRACTURES OF THE ULNA. 

to produce dislocations at the elbow-joint, unless we except direct 
crushing blows, which of course may break the bones at any point 
upon which the force happens to be applied. 

Symptoms. — Partial or complete displacement of the ulna, or of the 
radius and ulna backwards, accompanied with the usual signs of these 
luxations; to which may be possibly added crepitus; and it is fair to 
presume that in some examples the fragment carried forwards by being 
driven against the trochlea, may be felt displaced and movable in the 
bend of the elbow. Brassard affirms that it was so with the patient 
whom he saw. If only the summit is broken off, the brachialis anticus 
could have no influence upon it, but if it were broken fairly through 
the base, it might be displaced slightly in the direction of the action 
of this muscle. 

The symptoms, however, which have been regarded as most diag- 
nostic, are the disposition to re-luxation manifested in most of these 
examples when the extension has been discontinued ; and especially 
the fact that the olecranon was particularly prominent when the arm 
was extended, but that it resumed its natural position when the arm 
was flexed to a right angle. But I am unable to understand how 
either of these circumstances can be better explained upon the suppo- 
sition of a fracture of this apophysis, than without such a supposition, 
If the reduction of both bones is once effected, even though the sup- 
port of the coronoid process is completely lost, the head of the radius 
ought to prevent a re-luxation unless the arm is disturbed again; nor 
can I understand why, when the elbow is bent, the re-luxation is less 
likely to occur ; since, although in this position the humerus bears 
less directly upon the process, the difference in this respect must be 
very little, for in whatever position the arm is placed, so long as the 
radius retains its position the ulna cannot be drawn very forcibly 
against the humerus ; while, on the other hand, by flexing the arm 
the power of the biceps and of such fibres of the brachialis as remain 
attached to the ulna, to aid in the maintenance of reduction is com- 
pletely lost ; and at the same moment the resistance, and consequent 
power of the triceps to produce the luxation, are greatly increased. 

In short, we must confess that we are here, also, notwithstanding 
the confidence with which writers have spoken of the signs of this 
accident, very much in doubt ; nor do we see how these doubts can 
be removed until we have in detail the symptoms of at least one 
example, the indubitable existence of which has been subsequently 
verified by dissection. 

Prognosis, — In the case of Cooper's patient, seen several months 
after the accident, the ulna projected backwards while the arm was 
extended, but it was without much difficulty drawn forwards and bent, 
and then the deformity disappeared. He thought that during exten- 
sion the ulna slipped back behind the inner condyle of the humerus. 
Brassard's patient, seen after three months, retained the power of pro- 
nation and supination, with also extension, but flexion was completely 
impossible, the forearm being arrested in this direction by the small, 
slightly movable fragment of bone in front of the elbow-joint, and 
which was supposed to be the process itself. Penneck's old man, who 



COKONOID PROCESS OF THE ULNA. 305 

Lad met with the accident in boyhood, had still the radius luxated 
forwards and outwards, and the olecranon more salient backwards than 
in the sound arm. Extension and flexion were nearly but not quite 
complete. Fahnestock informs us that his patient " recovered com- 
pletely," but whether without deformity or maiming we are not told. 
Couper says the bone was united in four weeks, and that only a slight 
deformity and a little stiffness remained. Physick's patient made a 
perfect recovery. 

Let us come again to the dissections. Rejecting the doubtful 
specimen belonging to Dr. Gibson, we have an exact account of only 
two, and, indeed, Sir Astley Cooper alone has described the mode of 
union. Samuel Cooper says that in the case of the University College 
specimen the radius is dislocated forwards and upwards, and the ole- 
cranon is displaced backwards, but he does not say whether the 
coronoid process has united, nor describe its position; but Sir Astley 
informs us that in the example seen and dissected by him the process 
was united by ligament, which was sufficiently long and flexible to 
allow the fragment to move upwards and downwards in the motions 
of flexion and extension. 

In the absence of any other testimony, we may be allowed to ex- 
press an opinion that when the fracture has taken place across the 
summit or above the insertion of the brachialis anticus, nothing but a 
ligamentous union can be regarded as possible, since the fragment 
can only derive nourishment from a few untorn fibres of the capsule 
and perhaps of the internal lateral ligaments; and although it may 
not be displaced, it cannot have the advantage of impaction, upon 
which alone, I suspect, a fracture of the neck of the femur within the 
capsule must rely for a bony union, if it ever does so unite. If, how- 
ever, the fracture has taken place at the base, and fortunately it has 
not become much displaced by the force of the concussion against the 
humerus, it does not seem to me so impossible that under favorable 
circumstances a bony union might now and then occur. It will be 
remembered that a good portion of the attachment of the brachialis 
anticus is still below the fracture, and the remaining fibres are not 
therefore very likely to displace the fragment, especially when the arm 
is sufficiently flexed, so as to properly relax this muscle. 

It will be of small importance, however, whether the union is bony 
or ligamentous, provided only there is not great displacement. 

Treatment. — Whatever view we take of the pathology of this acci- 
dent, the rational mode of treatment would seem to consist in flexing 
the arm at a right angle, and retaining it a sufficient length of time in 
that position; not forgetting, however, the danger of anchylosis from 
long-continued confinement in one position. 

An angular splint may be useful in preventing motion at first, but 
I think it ought not to be continued beyond seven or ten days at the 
most. After this, a simple sling is all that can be necessary, since 
from this period some motion must be given to the joint if we would 
take the proper precautions to prevent stiffness. Sir Astley Cooper 
thought the limb ought to be kept immovable three weeks, and Yel- 



306 FRACTURES OF THE ULNA. 

peau preferred four ; but I cannot agree with them, believing that the 
question of the future mobility of the elbow-joint is vastly more im- 
portant than the question of a bony or ligamentous union between 
the fragments. Couper says that he adopted in the treatment of the 
case reported by him, extreme flexion, but both Physick and Fahnes- 
tock placed the arm at right angles, and Sir Astley Cooper has re- 
commended the same position. The latter position has always the 
advantage in case permanent anchylosis occurs, and the former cannot 
add much to the chance of complete replacement of the fragment. 

Bandages are only serviceable to retain the splint in place, and they 
may be thrown aside as soon as the splint is removed. 



§ 3. Fractures of the Olecranon Process. 

Causes. — My records furnish me with accounts of only seven of these 
fractures, and so far as I have been able to ascertain, all were occa- 
sioned by falls upon the elbow, or by blows inflicted directly upon 
the part. Malgaigne has, however, been able to collect accounts of 
six examples of fracture of the olecranon, produced, as is affirmed, by 
the violent action of the triceps ; as in pushing with the arm slightly 
flexed, in throwing a ball, in plunging into the water with the arms 
extended, etc. ; but only four of these reported examples does he think 
are sufficiently authenticated to entitle them to be received as facts ; 
nor do I think it possible to affirm positively that in any instance, 
where the whole process is broken off, the triceps alone has occasioned 
the separation. For example, Capiomont reports the case of a cavalier, 
who, being intoxicated, was thrown head foremost from his horse, and 
striking probably upon his hand, was found to have broken the 
olecranon process. We do not, in this example, see evidence alone 
of a forcible contraction of the triceps, but also of violent pressure 
against the hand and in the direction of the axis of the forearm toward 
the elbow-joint, by which the olecranon process might have been so 
thrown forwards against the fossa of the humerus as to cause its 
separation. The same explanation might apply to several of the 
other examples. 

Point and Direction of Fracture ; Displacement, etc. — The process may 
be broken at its summit, at its base, or intermediate between these two 
extremes, the last of which is the most common. 

It is probable that when the action of the triceps alone has produced 
the fracture, it will be found that only the summit, or that portion 
which receives the insertion of the triceps, has been broken off. Mal- 
gaigne, who has been able to find upon record only two cases of a frac- 
ture of the extreme end of the process, declares that they were both 
occasioned by muscular action. 

Fractures of the middle are generally transverse, or only slightly 
oblique, occurring in the line of the junction of the epiphysis with 
the diaphysis. We think, also, we have reasons for believing that 
these only occur as a consequence of a fall upon the elbow, or of a 




FKACTUKES OF THE OLECKANON PKOCESS. 307 

blow upon the extreme point of the elbow, when the forearm is con- 
siderably flexed upon the arm ; the direction of the obliquity, when 
any is found to exist, being gene- 
rally from above downwards and Fig. 92. 
from behind forwards, indicating 
that the direction of the force was 
also from behind. 

Fractures through the base are 
generally quite oblique, the line 
of fracture extending from before 
downwards and backwards, so that 
not only the whole of the process, 
but a portion of the back of the 

shaft is carried away ; and this ac- Fracture at the 

cident can scarcely happen, except 
by a blow received upon the lower end of the humerus, directly in 
front of the process ; or, what would amount to the same thing, by a 
blow from behind, received upon the ulna just below the olecranon 
process, or by wrenching the forearm violently back, while the humerus 
is fixed. 

The only displacement to which the upper fragment seems to be 
liable, is in the direction of the triceps ; aud the degree of this dis- 
placement does not depend so much upon the point at which the 
fracture has taken place as upon the violence which has occasioned it, 
the extent of the disruption of the ligaments, aponeurosis of the triceps 
and of the capsule, and upon whether, since the accident, the arm has 
been flexed or kept extended. 

In three instances, I have found distinct crepitus immediately after 
the fracture had occurred, produced by only moving the fragment 
laterally, showing plainly that little or no displacement had taken 
place. The following example will show also that this displacement 
does not always happen even after the lapse of several days, and where 
no surgical treatment has been adopted. 

Samuel Duckett, set. 14, fell upon the point of the elbow, and two 
days after was admitted to the Buffalo Hospital of the Sisters of 
Charity. The elbow was then much swollen, but no crepitus could 
be detected, and he could nearly straighten his arm by the action of 
the triceps. On the sixth day, the swelling having sufficiently .sub- 
sided, a distinct crepitus was discovered when the olecranon process 
was seized between the fingers, and moved laterally. We extended 
the arm immediately, and applied a long gutta-percha splint to the 
whole front of the arm and forearm, securing it in place with a roller. 
On the eleventh day, five days after the first dressing, the splint was 
taken off, and its angle at the elbow-joint slightly changed ; and this 
was repeated every day until the twenty- second from the time of the 
accident. The splint was then finally removed, when the fragment 
was found to be united without any perceptible displacement, and the 
motions of the joint were unimpaired. 

It must not be inferred, however, that it is always prudent to leave 
this fracture thus unsupported, since it has occasionally happened 



808 FKACTUKES OF THE ULNA. 

that the displacement, which did not exist at first, has taken place to 
the extent of half an inch or more, after the lapse of several days. 
Mr. Earle mentions a case in which the separation did not take place 
until the sixth day, when it was occasioned by the patient's attempting 
to tie his neckcloth. 

Symptoms. — The usual signs of a fracture of the olecranon process, 
are, when the fragments are not separated, crepitus discovered espe- 
cially by seizing the process, and moving it laterally ; or, when dis- 
placement has actually taken place the crepitus may be discovered 
sometimes by extending the forearm, and pressing the upper fragment 
downwards until it is made to touch the lower fragment; the existence 
of a palpable depression between the fragments, partial flexion of the 
forearm, and total inability, on the part of the patient, to straighten 
it completely, or even to flex the arm in some cases. If the fragments 
do not separate, gentle flexion and. extension of the arm, while the 
finger rests upon the process, may enable us to detect the fracture. 

It will sometimes happen that, owing to the rapid occurrence of 
tumefaction, the evidences of a fracture will be quite equivocal ; but, 
in all cases where a severe injury has been inflicted upon the point 
of the elbow, it will be well to suspend judgment until, by repeated 
examinations, made on successive days, the question is determined. 
Meanwhile, the arm ought to be kept constantly in an extended posi- 
tion, as if a fracture was known to exist. 

Prognosis. — In a large -majority of cases, this process becomes re- 
united to the shaft by ligament, which may vary in length from a 
line to an inch or more, and which is more or less perfect in different 
cases. Sometimes it is composed of two separate bands, with an 
intermediate space, or the ligament may have several holes in it ; at 
other times it is composed in part of bone and in part of fibrous tissue ; 
but most frequently it is a single, firm, fibrous cord, whose breadth and 
thickness are less than that of the process to which it is attached. 

If the fragments are maintained in perfect apposition, a bony union 
may occur, yet it is not invariably found to have taken place, even 
under these circumstances. Malgaigne thinks, also, he has seen one 
case in which there was neither bone nor fibrous tissue deposited be- 
tween the fragments. This was an ancient fracture at the base of the 
olecranon ; the superior fragment remained immovable during the 
flexion and extension of the arm, yet it could be moved easily from 
side to side. 

In my own cases, I have three times found the fragments united 
without any appreciable separation, and have presumed that the union 
was bony. One of these examples I have already mentioned ; the 
second, was in the person of a lady aged about forty years, who, 
having fallen down a flight of steps on the 8th of September, 1857, 
sent for me immediately. I found a large bloody tumor covering the 
elbow-joint, but there was no difficulty in detecting a fracture of the 
olecranon process. It was easily moved from side to side, and this 
motion was accompanied with a distant crepitus. During the first 
week, the arm was only laid upon a pillow, but as it was found to 
become gradually more flexed, and the swelling having in a great 



FRACTURES OF THE OLECRANON PROCESS. 



:09 



Fig. 93. 




Union by ligament. 



measure subsided, the arm was nearly, but not quite, straightened, 
and a long gutta-percha splint applied to the palmar surface of the 
forearm and arm. The fragments united in about 
twenty or twenty -five days, and without separation, so 
far as could be discovered in a very careful exami- 
nation. 

The third example to which I have referred, occurred 
in a boy fourteen years old, and was treated by Dr. 
Benjamin Smith, of Berkshire, Massachusetts. Sixty- 
nine years after, he being then eighty-three years old, 
I found the olecranon process united apparently by 
bone, but to that day he had been unable to straighten 
the arm completely, or to supine it freely. 

In one instance I found the fragment, after the lapse 
of one year, united by a ligament, which seemed to be 
about one-quarter of an inch in length, and the arm 
appeared to be in all respects as perfect as the other. 
He could flex and extend it freely. 

In the two following examples, also, the bond of 
union was ligamentous : — 

John Carbony, aet. 18, having broken the olecranon, 
it was treated with a straight splint. Nine years after, 
I found the process united by a ligament half an inch in -length, and 
he could nearly, but not entirely, straighten the arm. In all other 
respects the functions and motions of the arm were perfect. 

A lad, set. 15, was brought to me by Dr. Lauderdale, a very excel- 
lent surgeon in the town of Geneseo, Livingston Co., N. Y., whose 
olecranon process had been broken by a fall six months before, and 
at the same time the head of the radius had been dislocated forwards. 
I found the radius in place, and the olecranon process united by a 
ligament about half an inch in length. Lie was not able to straighten 
the arm completely, the forearm remaining at an angle of 45° with 
the arm. 

Treatment. — It will surprise the student who is yet unacquainted 
with the literature of our science, to learn that in relation to the treat- 
ment of a fracture of the olecranon process, a wide difference of opinion 
has been entertained as to what ought to be the position of the arm 
and the forearm, in order to the accomplishment of the most favorable 
results ; and that, while some insist upon the straight position as essen- 
tial to success, others prefer a slightly flexed position, and still others 
have advocated the right-angled position. Thus, Hippocrates, and 
nearly all of the earlier surgeons, down to a period so late as the latter 
part of the last century, directed that the arm should be placed in a 
position of demi-flexion ; Boyer, Desault, and, after them, most of the 
French surgeons of our own day, prefer a position in which the fore- 
arm is very slightly bent upon the arm ; while Sir Astley Cooper, and 
a large majority of the English and American surgeons, employ com- 
plete or extreme extension. 

The arguments presented by the advocates and antagonists of these 
various plans deserve a moment's consideration. 



310 FEACTUKES OF THE ULXA. 

In favor of the position of clemi -flexion, requiring no splints, and, 
in the opinion of some writers, not even a bandage, but only a sling 
to support the forearm, it is claimed that it leaves the patient at liberty 
at once to walk about and to move the elbow-joint freely, so soon at 
least as the subsidence of the swelling and pain will permit, and that 
in this way the danger of anchylosis is greatly diminished ; that more- 
over, if anchylosis should unfortunately occur, the limb is in a much 
better position for the proper performance of its most ordinary func- 
tions than if it were extended. Some have also added to this argu- 
ment a statement that a fibrous union, under any circumstances, is 
inevitable, and that it is a matter of little consequence whether the 
ligament thus formed is long or short, since in either condition it will 
be equally serviceable. 

In reply to these statements, it may be said briefly that they are 
nearly all based upon false premises, or that they have been proven 
in themselves to be essentially erroneous. 

Anchylosis is always a serious event, which by all possible means 
the surgeon will seek to prevent, but position has nothing to do with 
determining this result ; when it does occur, it may usually be ascribed 
either to the severity and complications of the original injury, to the 
violence of the consequent inflammation, or to having neglected, at a 
proper period and with sufficient perseverance, to move the joint. 

That a fibrous union is inevitable under any circumstances, has 
been fully proven to be an error ; and it has been equally proven that 
the functions of the arm are generally impaired in proportion to the 
length of the uniting medium. 

The only argument which remains, and which really possesses any 
weight, is, that, if permanent anchylosis does actually occur, the arm, 
when demi-flexed, is in a better position for the performance of its 
ordinary functions ; and this, considered as an argument in favor of 
the universal or even general adoption of the flexed position, is suc- 
cessfully met by a statement of the infrequency of permanent anchy- 
losis after a simple fracture, when the case has been properly treated, 
whether by the flexed or straight position ; while, if the limb is flexed, 
a maiming, as a result of the great length of the intermediate liga- 
ment, is almost inevitable. 

Yet if, in any case, from the great severity and complications of the 
injury, especially in certain examples of compound and comminuted 
fracture, it were to be reasonably anticipated that permanent bony 
anchylosis must result, or even where the probabilities were strongly 
that way, the surgeon might be justified in selecting for the limb, at 
once, the position of demi-flexion ; or he might leave the arm without 
a splint, and at liberty to draw up spontaneously and gradually to this 
position, as it is always very prone to do. 

In favor of moderate, but not complete extension, it is claimed that 
it is less fatiguing than the latter position, while it accomplishes a 
more exact apposition of the fragments, if they happen to be brought 
actually into contact. 

I am unable, however, to understand how the apposition can be 
rendered less exact by complete extension, unless by this is meant a 



FEACTUEES OF THE OLECRANON PROCESS. 311 

degree of extension beyond that which is natural, and which, I am 
well aware, is permitted to the elbow-joint when this posterior brace 
is broken off, It would certainly derange the fragments to place the 
arm in this extreme condition of extension — that is, in a condition of 
extension approaching dorsal flexion, which is certainly beyond what 
is natural. Indeed, perhaps we may admit that, in order to perfect 
apposition, the extension ought to be less by one or two degress than 
what is natural, sufficient to compensate for the trifling amount of 
effusion which may be presumed to have occurred in the olecranon 
fossa, and which would prevent the process from sinking again fairly 
into its fossa. 

As to its being less fatiguing, it is well known to those accustomed 
to treat fractures of the thigh by permanent extension that the muscles 
rapidly acquire a tolerance, which soon dissipates all feeling of fatigue, 
and that, after a few hours, or days at most, the patients express them- 
selves as being more comfortable in this position than in the flexed. 

Finally, the advocates of complete, natural extension claim that in 
this position alone, is the triceps most perfectly relaxed, and conse- 
quently the most important indication, namely, the descent of the ole- 
cranon, most fully accomplished. In this opinion we also concur ; and 
regarding all other considerations, in the early days of the treatment, 
as secondary to this one, we unhesitatingly declare our preference for 
what has been called the "position of complete extension," as opposed 
to flexion, demi-flexion, or extreme extension. 

It only remains for us to determine by what means the limb can be 
best maintained in the extended position, and the olecranon process 
most easily and effectually secured in place. 

For this purpose a variety of ingenious plans have been devised ; 

Fig. 94. 




Sir Astley Cooper's method. 

such as the compress and "figure-of-8" bandage of Duverney, without 
splints ; or a similar bandage employed by Desault, with the addition 
of a long splint in front ; the circular and transverse bandages of Sir 
Astley Cooper, with lateral tapes to draw them together, to which 
also a splint was added; and many other modes not varying essentially 
from those already described, but nearly all of which are liable to one 
serious objection, namely, that if they are applied with sufficient firm- 
ness to hold upon the fragment, and Boyer says they " ought to be 
drawn very tight," they ligate the limb so completely as to interrupt 
its circulation, and expose the limb greatly to the hazards of swelling, 
ulceration, and even gangrene. How else is it possible to make the 
bandage effective upon a small fragment of bone, scarcely larger than 
the tendon which envelops its upper end, and with no salient points 



312 



FRACTURES OF THE ULNA, 



against which the compress or the roller can make advantageous 
pressure? If, then, these accidents, swelling, ulceration, and gan- 
grene, are not of frequent occurrence, it is only because the bandage 
has not been generally applied "very tight," and while it has plone 
no harm, it has as plainly done no good. 

The dangers to which I allude may be easily avoided, without re- 
laxing the security afforded by the compress and bandage, b} 7 a 
method which is very simple, and the value of which I have already 
sufficiently determined by my own practice. 

The surgeon will prepare, extemporaneously always, for no single 
pattern will fit two arms, a splint, from a long and sound wooden 
shingle, or from any piece of thin, light board. This must be long- 
enough to reach from near the wrist-joint to within three or four 
inches of the shoulder, and of a width equal to the widest part of the 
limb. Its width must be uniform throughout, except that, at a point 
corresponding to a point three inches, or thereabouts, below the top 
of the olecranon process, there shall be a notch on each side, or a 
slight narrowing of the splint. One surface of the splint is now to be 

Fig. 95. 




Fig. 




The author's method. 



thickly padded with hair or cotton-batting, so as to fit all of the in- 
equalities of the arm, forearm, and elbow, and the whole covered 
neatly with a piece of cotton cloth, stitched together upon the back 
of the splint. Thus prepared, it is to be laid upon the palmar surface 
of the limb, and a roller is to be applied, commencing at the hand 
and covering the splint, by successive circular turns, until the notch 
is reached, from which point the roller is to pass upwards and back- 
wards behind the olecranon process and down again to the same 
point on the opposite side of the splint; after making a second oblique 
turn above the olecranon, to render it more secure, the roller may 
begin gradually to descend, each turn being less oblique, and pas 
through the same notch, until the whole of the back of the elbow- 
joint is covered. This completes the adjustment of the fragments, 



FRACTURES OF THE OLE CRANON .PROCESS. 813 

and it only remains to carry the roller again upwards, by circular 
turns, until the whole arm is covered as high as the top of the splint. 

The advantage of this mode of dressing must be apparent. It 
leaves, on each side of the splint, a space upon which neither the 
splint nor bandage can make pressure, and the circulation of the limb 
is, therefore, unembarrassed, while it is equally effective in retaining 
the olecranon in place, and much less liable to become disarranged. 

Before the bandage is applied about the elbow-joint, the olecranon 
must be drawn down, as well as it can be, by pressure with the 
fingers, and a compress of folded linen, wetted to prevent its sliding, 
must be placed partly above and partly upon the process; at the same 
time, also, care must be taken that the skin is not folded in between 
the fragments. 

This dressing ought, no doubt, to be applied immediately, since, if 
we wait, as Boyer seems to advise, until the swelling has subsided, it 
will be found much more difficult to straighten the arm completely 
than it would have been at first, and the olecranon process will be more 
drawn up and fixed in its abnormal position. Something will be 
gained by these means, adopted early, even if the bandage cannot be 
applied tightly, and moderate bandaging will not in any way interfere 
with the proper and successful treatment of the inflammation. We 
must always keep in mind, however, the fact that the fracture being 
usually the result of a direct blow, considerable inflammation and 
swelling around the joint are about to follow rapidly; and on each suc- 
cessive day, or oftener if necessary, the bandages must be examined 
carefully, and promptly loosened whenever it seems to be necessary. 
For this purpose it is better not to unroll the bandages, but to cut 
them with a pair of scissors, along the face of the splint, cutting only 
a small portion at a time, and as they draw back, stitch them together 
again lightly ; and thus proceed until the whole has been rendered 
sufficiently loose. 

As soon as the inflammation has subsided, and as early sometimes 
as the fifth or seventh day, the dressings ought to be removed com- 
pletely ; and while the fingers of the Surgeon, resting upon the compress, 
sustain the process, the elbow ought to be gently and slightly flexed 
and extended two or three times. From this time forward, until the 
union is consummated, this practice should be continued daily, only 
increasing the flexion each time, as the inflammation and pain may 
permit. If it is thought best, at length, to change the angle of the 
arm, and to flex it more and more, it may be done easily by substi- 
tuting a very thick sheet of gutta percha for the board. 

Dieffenbach has several times, in old fractures of both the olecranon 
and patella, where the fragments were dragged far apart, divided the 
tendons, so as to be able to bring the two portions together, and, by 
friction of them one upon the other, has endeavored to excite such 
action as might end in the formation of a shorter and a firmer bond of 
union. In some instances, it is said, considerable benefit was obtained, 
after all other means had failed ; in others, the result was negative. 
One example of an old ununited fracture of the olecranon is mentioned, 
21 



314 FRACTURES OF THE RADIUS AND ULNA. 

in which, he divided the tendon of the triceps, secured the upper frag- 
ment in place, and every fourteen days rubbed it well against the 
lower one; in three months "the union was firm:' 1 

The practice, not without its hazards, needs further observations to 
determine its value. 

Recently a gentleman called upon me with his son, aged seven years, 
who had an unreduced dislocation of the radius and ulna backwards 
of nine weeks' standing. While reducing this dislocation, it being 
necessary to flex the arm forcibly, the epiphysis constituting the 
olecranon process gave way, and became separated from one- half to 
three-quarters of an inch. This is the only example of separation of 
this epiphysis which has come to my knowledge. 



CHAPTEE XXIII. 

FRACTURES OF THE RADIUS AND ULXA. 

Causes. — In a large majority of the examples of this fracture seen 
by me, which have been of such a character as to warrant an attempt 
to save the limb, the accident has been occasioned by a fall upon the 
palm of the hand while the arm was extended in front of the body. 
Yet this cause is not so constant as in fractures of the radius alone, 
since a considerable number have been occasioned by direct blows ; 
and if we were to add to this estimate all of those bad compound frac- 
tures which have demanded immediate amputation, the proportion of 
fractures occasioned by direct and indirect blows might be found to 
be pretty nearly balanced. 

Point of Fracture, Character, Direction of Displacement &c. — In a 
record of sixty fractures of both bones, not including gunshot frac- 
tures, or those demanding immediate amputation, I have found six 
broken in the upper third; twenty-four in the middle third, and thirty 
in the lower third. 

Fig. 97. 




Fracture in the middle third. 



In one case the radius was broken three-quarters of an inch above 
its lower end, and the ulna about one inch below the coronoid process. 

1 Dieffenbach, American Journal of Medical Science, vol. xxix. p. 47S ; from Cas- 
per's Wochenschrift, Oct. 2d, 1841. 



FRACTURES OF THE RADIUS AND ULNA 



315 



Fracture in the 
lower third 



Four of the fractures belonging to the lower third were Fig- 

probably epiphyseal separations. ^| 

Forty-six were simple, eight compound, one was 
comminuted, three both compound and comminuted, 
one complicated with a fracture of the humerus, and 
one with a partial luxation of the lower end of the 
radius. With three exceptions, all of these more 
serious accidents were arranged among fractures of the 
lower third, and generally the bones had been broken 
near the wrist. 

Partial fractures have been frequently observed, but 
having treated of these accidents fully in the general 
chapter on Incomplete Fractures, I shall not think it 
necessary to make any further allusion to them in this 
place. 

Prognosis. — Generally these bones unite in from 
twenty to thirty days; but I have seen the union 
occasionally delayed considerably beyond this time, 
and this delay has occurred especially in the case of 
the radius. Thus, in three cases of compound and 
comminuted fracture, the ulna united within four or 
five weeks, while the radius did not unite until the 
ninth or tenth week. Twice in simple fractures the 
ulna has united in the usual time, but the radius not until the six- 
teenth week. Once the ulna has united promptly and the radius 
remained ununited at the end of two years, at which time I practised 
resection of the broken ends of the radius, and union 
was speedily established. 

On the other hand I have once seen the union de- 
layed four months in the case of the ulna, when the 
radius had united in the usual time ; and in one ex- 
ample of compound fracture both bones refused to 
unite until after the fifth month. 

Thirty-three of the whole number have united with- 
out any appreciable deformity, and fifteen are known 
to have left some marked defect, while two have re- 
sulted finally in the loss of the arm. Of the remainder 
I cannot speak positively. 

I have seen the fragments deviate slightly in almost 
every direction, but most often it has been noticed that 
the deviation was to the radial or ulnar sides. Thus, 
in three examples, two of which had been com- 
pound fractures, the bones have united in such a 
position as that from the point of fracture downwards 
the forearm has been deflected to the ulnar side, and 
a marked projection has been left at the seat of frac- 
ture on the radial side; while in two examples, both 
of which were simple fractures, exactly the opposite 
condition has obtained, the lower part of the forearm 
being deflected to the radial side. 



Fig. 



A 



Uiiion with slight 
lateral displacement. 



316 FRACTURES OF THE RADIUS AND ULNA. 

In a majority of cases the hand has been left with some tendency 
to pronation ; in many instances this tendency was very slight and 
scarcely appreciable, but in others it has been quite marked, so that 
the patients have been wholly unable to supine the forearm except by 
a motion of the humerus in its socket. 

From what has been said it must be seen that the prognosis in these 
accidents takes the widest range: for while a larger proportion than 
in the case of almost any other of the long bones, unite without any 
appreciable deformity, a considerable number delay to unite or do not 
unite at all, and some, even where the fracture is most simple, result 
in the complete loss of the limb. I am not now speaking of those 
more severe accidents in which the limb is at once condemned to 
amputation, and which, in the case of the arm, are numerous ; but, as 
I have already mentioned, our observations here apply only to cases 
which came under treatment with a view especially to the fracture. 

I shall state the facts more fully, and then perhaps we shall think 
it proper to inquire why, when, as a rule, the treatment is found to be 
so simple and successful, occasionally, and pretty often indeed, it re- 
sults so disastrously. 

A boy, aged about ten years, fell from a tree, April 22, 1856, frac- 
turing the right forearm near the lower end of the middle third. It 
was evident that he had fallen upon the palm of his hand, as the lower 
fragments w r ere inclined backwards, and one of the bones had been 
thrust through the skin on the front of the arm. 

It was at first dressed carefully by Dr. Wilcox, but the father of the 
lad on the following day placed him under the care of an empiric. 

Six days after the fracture occurred, I was called to see him, with 
several other gentlemen. He was then suffering under a severe attack 
of tetanus which had commenced the night before. His arm was much 
swollen and very painful. He died the same evening. 

I was unable to learn very particularly what had been the treat- 
ment since the patient was seen by Dr. Wilcox, except that the band- 
ages had been most of the time very tight, and that the empiric had 
applied stimulating liniments, the boy constantly complaining greatly 
of the pain. I found the arm done up in a most slovenly manner with 
several narrow splints, underlaid with loose and knotty fragments of 
cotton batting. 

We removed all of these immediately, and laid the arm upon a 
cushion supported by a board, to both of which the arm was lightly 
secured by a few turns of a bandage ; cool water lotions were dili- 
gently applied and chloroform administered by inhalation ; but the 
fatal event was delayed only a few hours. 

I shall not stop to inquire the cause of a result so unfortunate, where 
the treatment has been so palpably unskilful. 

I have already mentioned one case of gangrene of the hand, after 
a fracture of the lower part of the humerus ; Norris, in a note to the 
American edition of Listorfs Surgery, mentions a case which came 
under his observation in the Pennsylvania Hospital, the fracture hav- 
ing taken place just above the condyles, and still another has been 
related to me lately. I have brought together also no less than six 



FRACTURES OF THE RADIUS AND ULNA. 317 

cases of sloughing of the arm, after fracture of the radius, and one of 
sloughing from tight bandaging, where the radius was supposed to be 
broken, although the dissection proved that it was not. 

Eobert Smith says, that similar cases have been recorded in the 
Gazette Medkale. To these I shall now add two examples of sloughing 
after fracture of both radius and ulna; making a total of twelve cases 
in the upper extremities, in addition to those reported in the Gazette 
Medicate, an exact account of which I have not seen. 

John McGrath, set. 9, fell, July 2, 1847, from a ladder, about thirty 
feet to the ground, breaking the right radius and ulna in their middle 
thirds. A surgeon was in attendance about four or five hours after 
the accident occurred. He then reduced the fractures and applied two 
broad splints, one on the palmar and one on the dorsal surface of the 
forearm. Whether a roller was first applied to the arm, or not, I am 
unable to say. The splints were secured in place by a roller and the 
arm laid in a sling. 

The third day was our national holiday, and the patient was not 
visited. Nor was he seen on the fourth day, not being found at home. 
On the fifth day the surgeon removed the bandages and found the arm 
gangrenous ; and within an hour afterwards I was requested to see it 
also. 

I found him lying in a miserable apartment, with his right arm 
resting upon a pillow. The arm, forearm, and hand were gangrenous 
through their whole extent; and the skin of the right side, on the 
front of the chest, had assumed a dusky color, the extreme margin of 
which was indicated by an abrupt crescentic line. The thumb and 
fingers were black. His countenance was bright and cheerful, and 
his mind intelligent ; pulse 75, and soft ; tongue clean. He had slept 
undisturbed the night before, and he had all along felt perfectly well, 
except that he had a slight diarrhoea. I was assured by the surgeon 
and by all of the family, that the bandages had not been applied 
tightly; but we were told that on the third day of the accident, having 
been locked into the house by his mother, who was a peddler, he 
climbed out of the window, and that during all of that, and most of 
the following day he was running about the streets firing crackers, 
during most of which time his arm was removed from his sling and 
hanging by his side. On the morning of the fourth day, his mother 
noticed that his fingers were black, but she thought they were stained 
with powder. 

We ordered him to take one-quarter of a grain of opium every 
four hours, and applied a yeast poultice to the arm. On the seventh 
day the gangrene was still extending, and the pulse was 124; yet he 
continued to feel well and to eat as usual. On the tenth day, the line 
of demarcation had commenced opposite the shoulder-joint ; and the 
crescentic discoloration on the breast, which had at first spread rapidly 
until it covered nearly the whole upper half of the chest, was quite 
faint, in some parts almost lost. 

In a few days more he was removed to the county almshouse, the 
separation continuing rapidly to take place until the arm fell off at 
the shoulder-joint ; after which he made a good recovery. 



318 FRACTUEES OF THE RADIUS AND ULNA. 

A child, two years and three months old, had fallen from a chair 
upon the floor, a distance of about two feet. A German physician 
"being called, found, as he believes, a fracture of both bones of the left 
arm. The fracture was near the middle. He immediately applied a 
roller from the fingers to the elbow, and over this three narrow splints 
made of the wood of a cigar box. One of these was laid upon the 
palmar, one upon the dorsal, and one upon the radial side of the fore- 
arm, and the whole were bound together by another roller. From 
this time until the tenth day the child continued to play about on the 
floor. Ten days after the accident occurred the doctor noticed that 
the ulnar side of the little finger was blue. The bandages were im- 
mediately removed, 'and were never again applied tightly. 

Three or four days after I was requested to see the arm with the 
attending physician. The gangrene had continued to extend, involving 
now the whole of the little finger and most of the thumb. There were 
also gangrenous spots over the hand and forearm, extending to within 
one inch from the elbow-joint ; these spots were more numerous in 
front and on the back of the forearm, and seemed to correspond to 
the pressure of the splints. The hand was much swollen, and also 
the arm above the line of the gangrene. The sloughs had already 
commenced to be thrown off, and the gangrene was only extending in 
a few points. The child appeared well and rather playful, except when 
the arm was being dressed. 

I ordered a yeast poultice, and a nourishing diet. 

I have since learned that the arm and a large portion of the hand 
were finally saved. 

South also says that he has seen one or two instances of mortifica- 
tion produced by splints applied too tightly, and previous to the acces- 
sion of the swelling after fracture, and which have not been loosened 
as the swelling increased. 1 

How shall we explain the frequency of these accidents after fracture, 
especially of the forearm ? 

Malgaigne, speaking of fractures of both bones of the forearm, re- 
marks that " when the displacement is considerable, or more especially 
when the outward violence has been excessive, we frequently see follow 
a very intense inflammatory swelling, and there is no fracture which 
complicates itself so easily with gangrene under the pressure of appa- 
ratus." 2 

Says Nelaton : " If we make choice of the apparatus of J. L. Petit, 
it is necessary that it shall not be applied too tightly, for, as Professor 
Eoux has long since remarked, fractures of the forearm are those 
which furnish most of the examples of gangrene in consequence of 
an arrest of the circulation. This is easily understood, if we consider 
on the one hand the superficial position of the two principal arteries 
of the forearm, and on the other the disposition of the apparel, which 
must almost infallibly compress the arteries to a great extent." 3 

1 South, note to Chelius's Surg., vol. i. p. 69. 

2 Malgaigne, Frac. et Disloc, torn. i. p. 589. 

3 IS'elatou, Pathologie Chirurgiuale, p. 735. 



FRACTURES OF THE RADIUS AND ULNA. 319 

I do not think that this accident is due always to the negligence of 
the surgeon. It may be cine many times to the carelessness of the 
parents or of the patient himself; as in the case of the boy who came 
under my own observation, and who lost his arm at the shoulder- 
joint. Sometimes also it may be due rather to the severity of the 
original injury, which, the experience of every surgeon will prove, is 
occasionally competent to the production of such bad results. A 
number of unfortunate circumstances may have concurred, such as a 
severe injury, especially where the skin has remained unbroken and 
the effused blood has had no opportunity to escape — the broken bone 
may have rested against the trunk of a main artery causing an arrest 
of its circulation — the constitution may be impaired by previous ill- 
ness, or it may be suffering under the shock of the injury; yet that it 
may be and too often is the result of maltreatment, on the part of the 
surgeon, is undeniable. It is proper, however, to discriminate between 
the responsibility which attaches to the surgeon as the true exponent 
of the state of his art, and that which attaches to the art itself as 
taught by the masters. 

The old surgeons applied first a roller to the hand and forearm, and 
over this their various splints. J. L. Petit thought he had made 
a valuable improvement upon this simple plan in laying over the 
roller a compress, supported by a splint, designed to press between 
the bones, and to antagonize thus the action of the roller in drawing 
the fragments toward each other. Duverney believed that this object 
would be best accomplished by placing the pad against the skin, and 
under a circular compress ; while Desault declares all of these modes 
inefficient, and announces a method which he regards as accomplishing 
at once and completely all of the indications ; the sole peculiarity of 
which method consists in placing the graduated pads against the skin, 
and securing them in place by a roller. Boyer adopts the same method 
without any modifications, and Mr. Hind, in his illustrations of frac- 
tures already referred to, has seen fit to recommend the same, at least 
in fractures of the radius. 

It is quite obvious that between these various methods there remains 
very little if anything to choose, the differences being too trifling and 
unessential to claim serious consideration. Each alike is inadequate 
to accomplish any amount of useful pressure between the fragments ; 
each alike is calculated to bind the bones one against the other, and 
each alike exposes to the danger of ligation and of gangrene. 

Says M. Dupuytren: "The practice of rolling the arm before the 
splints are applied, whether internal or external to the pads and com- 
presses, is eminently mischievous ; and instead of fulfilling, directly 
counteracts, the indications which it is most important to keep in view 
in the treatment of fractures of the forearm." 

And notwithstanding the same sentiment has been reiterated by 
Velpeau, Malgaigne, Nelaton, Samuel Cooper, Bransby Cooper, 
Erichsen, Amesbury, Gibson and others, yet we find to-day the great 
surgeon of Heidelburgh, Chelius, recommending the roller to be 
applied under the splints, after the manner of Desault: while Liston, 
Syme, and Fergusson, who perhaps represent the Edinburgh school, 



320 FRACTURES OF THE RADIUS AND ULNA. 

use only pasteboard splints above the compresses, over which is im- 
mediately applied the roller ; a practice which differs very little from 
that recommended by Desault, and is equally obnoxious to criticism. 

Among the American surgeons, I believe, the advice and practice 
of Dupuytren have received almost universal assent, only that we have 
always employed splints much wider than those recommended by 
this distinguished surgeon. I cannot therefore agree with my accom- 
plished countryman, Dr. Reynell Coates, if in the following para- 
graph he means to imply that American surgeons generally adopt 
Desault's treatment. Such at least is not my experience. " It would 
be wrong," says Dr. Coates, " not to bear testimony, on every possi- 
ble occasion, against the folly so universally prevalent, that induces 
surgeons to apply a bandage directly to the forearm before applying 
splints in injuries of this character. We have often asked for a ra- 
tional explanation of this practice, without effect. It is directly at 
war with the acknowledged indications in the coaptation of the frag- 
ments, and when the object of the whole apparatus is to thrust 
asunder their extremities, it commences bv binding them too-ether. 
Few plans in surgery are more generally followed ; none can be more 
absurd." 

Of the estimate placed upon the roller by M. Mayor, the reader 
will judge by a reference to the passage which I shall quote further 
on, when I shall speak of the value of the interosseous compresses. 

Amesbury and Bransby Cooper use no rollers at all — not even to 
secure the splints in place, they being made fast to the forearm by 
straps or tapes. 

Mr. Amesbury and Mr. South also endeavor to give to their splints 
an appropriate shape, by having them constructed with more or less 
convexity. It must be noticed, however, that the practice of these 
two gentlemen is very dissimilar, for while Mr. South applies the 
convex surface of his splint to the interosseous space, Mr. Amesbury 
reverses this plan, and applies the concave surface directly to the skin. 

As to the width of the splints, surgeons are also very generally 
agreed, at the present day, that they ought to be wider than the arm, 
so as to prevent the roller or the tapes from resting against its 
sides. 

I do not intend to deny peremptorily, and without qualification, the 
value of the graduated compresses, which, as we have seen, are usually 
laid along the interosseous space to press the fragments asunder. It 
is necessary, however, to caution the surgeon against their injudicious 
use. M. Xelaton has well remarked of the apparel employed by J. 
L. Petit, that it must inevitably compress, to a great extent, the 
arteries of the forearm; and the remark is applicable, in only a less 
degree, to all of those other plans in which the compress is employed. 
And I suspect that to this portion of the dressing, quite as much as to 
any other cause, are due those frightful accidents of which we have 
already spoken. The arteries are not only exposed, from their super- 
ficial position, to pressure from a compress,' but, in addition to this, it 
will be noticed that the two principal arteries, the radial and the ulnar, 
are situated upon a broad and flat surface of bone, along which this 



FEACTUEES OF THE RADIUS AND ULNA. 321 

pressure must operate most advantageously. So early as the year 
1833, M. Lenoir, in his inaugural thesis, at Paris, called attention to 
this danger, and from time to time surgeons have continued to advert 
to it, but they have seldom given to its consideration that prominence 
which its importance deserves. 

I have observed another fact in this connection : when this compress 
is extended low down on the palmar surface, within an inch or two of 
the wrist-joint, it soon becomes excessively painful, and sometimes 
even wholly insupportable, in consequence of the pressure made upon 
the median nerve; and I find myself always obliged to exercise great 
care in the adaptation of the pads at this point. For this reason alone 
I believe, in case of a fracture near the base of the radius, the lower 
fragment, if it were thrown toward the ulna, could not be retained in 
its place by graduated compresses. 

In short, finding that broad splints, properly covered and padded, 
answer very well to crowd the muscles into the interosseous space, so 
far as it is proper to do so, and believing that this mode is less painful 
and less dangerous, I seldom resort to graduated compresses, nor can 
I appreciate their necessity, or indeed, their utility. Mr. Lonsdale 
also concurs with me in attaching very little value to this part of the 
accustomed apparel. 

But listen to the surgeon of Lausanne, M. Mayor: "What signify 
graduated compresses placed between the bones of the forearm for 
the purpose of separating them from each other ? These bones will 
not have that constant tendency to approach each other which has 
been supposed, provided, first, that they have been well reduced ; 
second, that for the purpose of maintaining them in position we do 
not make use of a preliminary circular bandage, whose action is an 
absurdity ; and, in short, provided we make the retentive means act 
chiefly upon the palmar and dorsal surfaces of the forearm." 1 

M. Mayor proceeds to declare these convictions to be the result of 
his own experience, both in the treatment of simple and compound 
fractures of the forearm, and he intimates that in the use of the cir- 
cular bandage with compresses, surgeons seem to have rolled the arm 
into a cylinder and drawn the bones together, in order that they might 
tax their ingenuity to discover some means to again separate them. 

Surgeons have generally, after the splints have been applied, placed 
the forearm in a position of semi-pronation, or midway between su- 
pination and pronation, so that the radius should be uppermost; it 
being assumed that in this position the two bones are most nearly par- 
allel, and least inclined to displacement. Such, indeed, was the prac- 
tice of Hippocrates, Paulus JEgineta, Celsus, Albucasis, and of most 
surgeons down to this day ; but Lonsdale, Eobert Smith, Nekton, and 
South have lately called in question the correctness of this mode of 
dressing, at least when it is adopted as a universal rule. 

I have before mentioned, when treating of fractures of the ulna, 

1 Bandages et Appareils a Pansements, ou Nouveau Systeme de Deligation Chirur- 
gicale, par M. Mathias Mayor, Chirurg. en Chef de l'Hopital de Lausanne, Switzer- 
land. Paris ed. 1838, p. 345. 



322 FRACTURES OF THE RADIUS AND ULNA. 

that M. Fleury had, in one instance, been unable to bring the frag- 
ments into apposition except by forced supination of the forearm ; 
and in certain fractures we have seen the same position recommended 
by Lonsdale. 

Says Mr. South, in a note to Chelius: "In fractures of both bones 
the forearm is best laid supine ;" and Xelaton declares that in frac- 
tures of the radius and ulna at any point of their upper thirds it will 
be necessary to supine the arm, both in the reduction and during the 
subsequent treatment ; but that in fractures of the inferior two-thirds 
we may place the limb in a condition of semi-pronation. 

It seems very probable, however, that both of these gentlemen have 
received their suggestions from Mr. Lonsdale, who, as we have already 
seen, has treated the question very much at length, and who has finally 
declared his decided preference for the supine position in the treatment 
of all fractures of the forearm. His arguments are certainly very in- 
genious, and as applied to fractures of the radius above the insertion of 
the pronator radii teres, they seem altogether conclusive ; and, indeed, 
they commend themselves very strongly to our judgment, as applied 
to all fractures of the forearm. They are sustained also by the results 
of his own experience, and I see no good reason why they should not 
be more thoroughly examined and tested by other surgeons. The 
advantages which he claims for this method are more perfect coapta- 
tion of the broken ends, less liability of the fragments to encroach 
upon the interosseous space, and consequently less danger of anchy- 
losis between the bones, and of non-union of the fragments, more 
complete restoration of the power of supination, and less tendency to 
lateral distortion, or of falling off to the ulnar or radial sides. 

My own cases, treated by the usual method, have shown that while 
supination is frequently impaired, and sometimes entirely lost, prona- 
tion is rarely affected ; and that lateral displacements are much more 
common than displacements forwards or backwards. How this posi- 
tion, semi-pronation, may tend to the production of a permanent pro- 
nation, I have fully explained when speaking of fractures of the head 
of the radius ; and the influence of the same position, the forearm 
resting upon its ulnar margin in the sling, in the production of a 
lateral deviation is also easily understood. If the arm rests upon the 
sling so that its weight bears more upon the point of fracture than 
upon the extremities of the bones, then the ulna, or both ulna and 
radius, will incline gradually to the radial side, and the hand will fall 
off to the ulnar side ; or if the sling rests under the wrist or hand 
chiefly, the hand will ascend to the radial side, and the broken ends 
of the two bones will project to the ulnar side. 

If this plan is adopted, viz : laying the hand and forearm upon its 
back, instead of upon its ulnar margin, the elbow should remain at 
the side, the humerus falling perpendicularly from its socket ; and 
the forearm should rest in the sling directed forwards from the body. 

Finally, whatever may be the mode of dressing, let me repeat the 
injunction to examine the arm frequently. ISTo surgeon can do justice 
to himself, or to his patient, who does not look at the arm at least 



FRACTURES OF THE CARPAL BONES. 323 

once in twenty-four hours during the first ten or fourteen days, and 
in some cases' the patient ought to be seen twice daily. 

When the fracture is compound, it is often quite impossible to 
retain the forearm in the half-pronated position ; since, when thus 
placed, and only slightly supported, as it must necessarily be, it in- 
evitably falls over upon its palmar surface. 

There can be no doubt that in such a case we ought, from the first, 
if it is found practicable, to place it upon its back, in a position of 
complete or nearly complete supination. For this purpose, a single 
broad splint, carefully cushioned and covered with oiled cloth, is the 
most suitable. Upon this, the forearm is to be laid, and secured gently 
with a few turns of the roller. If the patient is able to do so, and 
wishes to walk about, the board may be suspended to the neck, as 
recommended by M. Mayor. 

I have said that we ought, in case of compound fracture, to lay the 
forearm upon its back, if practicable. I am sure, however, that the 
surgeon will find very many patients who cannot endure this position, 
and he may be compelled, therefore, to lay the limb upon its palmar 
surface, or to leave it to assume any other position in which it may 
be the most at ease. 



CHAPTEE XXIY. 

FRACTURES OF THE CARPAL BONES. 

The few cases of fracture of the carpal bones, which have come 
under my observation were, without exception, compound and com- 
plicated, and have resulted in the complete loss of the hand, or in 
some less serious, but never inconsiderable mutilation or maiming. 

In no case has a treatment been adopted which might be regarded 
as having • reference to the fracture, or the purpose of which was to 
insure apposition and union of the fragments. 

It may be proper to assume in a matter so easily comprehended, 
what actual and recorded experience has not proven, namely, that 
simple fractures of these bones will demand very little surgical inter- 
ference, and that they will unite generally without much displacement, 
and without any considerable maiming. It is, indeed, quite probable 
that some degree of anchylosis between their adjacent surfaces will 
occur, yet even in the normal condition they enjoy so little motion as 
to render it doubtful whether its complete loss would be very sensibly 
felt. 

In cases of comminuted, compound, and otherwise complicated frac- 
tures of the carpal bones, which accidents are sufficiently common, 
the surgeon has only, I conceive, to follow carefully those general or 
special indications which may happen to be present, the precise 



324: FRACTURES OF THE METACARPAL BOXES. 

character of which it would be difficult to anticipate, and for the treat- 
ment of which it would be unsafe to attempt in a written treatise to 
provide. 



CHAPTEE XXV. 

FRACTURES OF THE METACARPAL BONES. 

Development of Metacarpal Bones. — These bones are each formed 
from two centres of ossification. In the case of the metacarpal bones 
of the four fingers there is one centre for each shaft, and one for each 
distal extremity ; but in the case of the metacarpal bone of the thumb 
there is one centre for the shaft and one for the proximal extremity. 
All these epiphyses unite with the shafts at about the twentieth year. 

Causes. — These bones, also, are generally broken by direct blows ; 
and in that case the injury is often of such a character as to demand 
amputation, and does not therefore belong to that class of accidents 
of which it is the purpose of this volume to treat. Not an incon- 
siderable number, however, are the results of indirect blows, and es- 
pecially of blows upon the knuckles received in pugilistic encounters. 
Thus, in a record of thirteen fractures, I find this cause assigned in 
six ; in one other instance it was occasioned by falling upon the clenched 
fist, and in one by striking a board; so that the fracture has resulted 
from a blow upon the ends of the bones in eight of the thirteen 
examples. 

Dorsey, in his Elements of Surgery, mentions also that he has known 
the metacarpal bones to be fractured in pugilistic contests. 

Point of Fracture • Direction of Displacement • Symptoms. — Once the 
fracture has occurred in the metacarpal bone of the thumb; five 
times in the metacarpal bone of the index finger ; once in the second 
finger ; three times in the ring finger, and three times in the metacar- 
pal bone of the little finger. Two of those belonging to the ring finger, 
and the three occurring in the little finger, were produced by blows 
with the clenched fist, and in each instance the fracture was in the 
lower or distal third of the bone. Two of the fractures of the meta- 
carpal bone of the index finger were produced also in the same way ; 
but the fractures were near the middle of the bone. Of the whole 
number, six were broken through the lower third, five through the 
middle, and two through the upper third. 

In every instance where the bone is known to have been broken by 
a blow upon the knuckles, the lower end of the lower fragment was 
thrown toward the palm, and this fragment was salient backwards at 
the point of fracture. 

In the following case the bone was probably separated at the 
epiphysis. 

Thomas Eose, set. 8, fell down a flight of steps, Sept. 11, 1855, 



FRACTUEES OF THE METACARPAL BONES. 325 

breaking the metacarpal bone of the index finger of the right hand 
near its lower extremity, and apparently at the junction of the epi- 
physis with the diaphysis. 

I saw the lad about sixteen hours after the accident. The lower 
fragment, projecting abruptly into the palm of the hand, could be 
easily replaced, or with only moderate effort, yet immediately when 
the support was removed it would become displaced. There was no 
crepitus. 

It was dressed very carefully with a splint and compress; but 
notwithstanding our continued efforts to keep the fragments in place, 
the epiphysis united considerably depressed toward the palm. 

In one instance, also, I think the bone was rather bent, or partially 
fractured, than broken completely. This was the case of fracture of 
the metacarpal bone of the ring finger, produced in a gymnasium by 
striking with the clenched fist against a board, and to which I have 
already alluded. I did not see the young man until four weeks after 
the accident, when I found the lower end of the bone depressed toward 
the palm and the angle made at the point of fracture was rather 
rounded and quite smooth ; it was also tender at this point, but the 
bone was firm and unyielding. Four years after I was permitted to 
examine it again, and I found the same slight deformity still con- 
tinuing. 

A partial explanation of the fact that the joint end of the lower frag- 
ment is generally displaced toward the palm, may be found in the 
natural curve of these bones, which is such that when the fracture has 
been produced by a counter-stroke, the distal end would almost neces- 
sarily be driven in this direction ; and a further explanation has been 
suggested by Mr. B. Cooper, namely, the action of the interossei.* 

Results. — Generally, when the fracture is simple, and the displace- 
ment is not considerable, the nature of the accident is overlooked, and 
some deformity must inevitably ensue. In a majority of the cases 
which have come under my observation this has been the fact, and 
the bone has remained slightly bent at the seat of fracture, but with- 
out affecting in any degree the value of the hand. 

The following example has furnished the most serious result of 
any case of simple fracture of these bones which has come under my 
notice. 

Louis Mooney, set. 25, struck a man with his clenched fist, Nov. 4, 
1856, breaking the metacarpal bone of the index finger of the right 
hand, near its middle. Great swelling and suppuration followed the 
injury. 

February 21, 1857, nearly four months after the injury was re- 
ceived, he consulted me. There existed at this time a complete anchy- 
losis at the wrist-joint, and partial anchylosis in the fingers. The hand 
was deflected forcibly to the radial side. At the point of fracture the 
fragments were salient backwards and quite prominent, but firmly 
united. 

Even when the existence of the fracture is recognized, it is not 
always easy to retain the fragments in place, as the case of epiphyseal 
separation already mentioned, and the following case, will illustrate. 



326 FRACTURES OF THE METACARPAL BOXES. 

Miss E., of Erie Co., N. Y., aet. 18, fell, Aug. 7, 1S53, striking upon 
her right hand with her fingers forcibly bent into the palm of the 
hand. On the following day she consulted me at my office, and I 
found the metacarpal bone of the ring finger broken about three- 
quarters of an inch from its lower end, and the distal extremity of 
the fragment depressed toward the palm. A feeble crepitus, with 
distinct motion, completed the diagnosis. The young lady was very 
anxious to have a perfect hand, and I was determined if possible to 
accomplish it. Finding that the lower fragment was constantly dis- 
posed to fall toward the palm, I constructed a gutta-percha splint for 
the hand and fingers, and after placing a pad directly underneath this 
fragment, I secured it firmly with a roller. From this time until the 
end of four weeks she remained under my care, visiting me as often 
as once or twice a week; and at each dressing I found the lower frag- 
ment slightly displaced in the same direction as at first, nor was I able 
ever to make it resume completely its position. 

Ordinarily, however, no such difficulty is experienced, and the bone, 
supported by such simple means as we shall presently direct, unites 
quickly and without deformity. 

An engineer was struck by a piece of iron in such a way as to break 
his right forearm and the second metacarpal bone of the same band. 
The fracture of the metacarpal bone was compound and about three- 
quarters of an inch from its proximal extremity. When he called 
upon me, which was immediately after the injury was received, I 
found the proximal fragment projecting directly backwards, its sharp 
point rising above the skin ; into which position it was evidently 
drawn by the action of the extensor carpi radialis longior muscle. 
By pressure alone it could be replaced, but it was much more easily 
reduced when the hand was forcibly carried backwards on the fore- 
arm. I therefore secured the hand in this position with appropriate 
splints, and it was maintained in this posture during most of the sub- 
sequent treatment. Union finally took place, but not without some 
backward displacement. Four months after the accident occurred, on 
the 31st of Dec. 1858, I examined the hand, and found the skin 
healed over completely, the end of the fragment having become 
rounded and smooth so as not to give him any degree of annoyance. 
His wrist was as flexible and as strong as before. No doubt the pro- 
jection of the fragment might have been prevented entirely by cutting 
at the point of its attachment the tendon of the extensor muscle, but 
this would have sensibly weakened the wrist-joint, and I preferred the 
alternative of a projection of the fragment. 

Treatment. — With moderate extension made upon the finger cor- 
responding to the broken bone, while the fragments are forced home 
by firm pressure, the bone may generally be brought at once into line, 
and we may now proceed to adapt a gutta-percha, felt, or thick paste- 
board splint, to either the whole surface of the back or palm of the 
hand and fingers, while they are held in a position of easy flexion. 
It is not very material to which of these surfaces the splint is applied ; 
or rather, I may say, it ought to be applied to the one or the other 
according as circumstances seem to indicate. It should be well pad- 



FRACTURES OF THE FINGERS. 327 

ded, and especially at certain points, in order to the more effectual 
support of the fragments. It is then to be secured in place with 
several turns of a roller. When either of the metacarpal bones, ex- 
cept those of the great or ring finger, is broken, the splint must be 
wide enough to secure the sides of the hand against the pressure of 
the roller. 

Thus dressed, the hand may be laid in a sling beside the chest, or 
while sitting it may rest upon a table. 

The apparel must be examined daily, and readjusted as often as it 
shall become disarranged, or as a doubt shall arise as to the condition 
of the parts. 

When the fracture is followed by much inflammation or occurs 
near, and especially if it actually involves a joint, the same precau- 
tions must be adopted to prevent anchylosis as in the case of similar 
fractures in other bones. 



CHAPTEE XXYI. 

FRACTURES OF THE FINGERS. 

Development of the Phalanges of the Hand. — The phalanges of the 
hand are formed from two centres of ossification, namely, one for each 
shaft and one for each proximal end. Ossification commences in the 
shafts at about the sixth week ; in the epiphyses of the first phalanges 
between the third and fourth years, and in the epiphyses of the two 
last phalanges somewhat later. Complete bony union takes place 
between the epiphyses and the shafts at from the eighteenth to the 
twentieth year. 

Causes. — I do not remember to have seen a fracture of one of the 
phalanges produced by a counter-stroke ; I am aware, however, that 
they are occasionally produced in this way, as by falling upon the 
ends of the fingers, and especially by the stroke of a ball in the game 
of base. 

The fact, however, that they are generally the consequence of a 
direct blow, and that the finger bones are small and only protected by 
a thin covering of skin and tendons, renders them peculiarly liable to 
comminution and to other serious complications. Thus, in a record 
of thirty fractures, only eighteen were sufficiently simple to warrant 
an attempt to save them ; and only five are recorded as simple frac- 
tures without complications. 

Point of Fracture and Direction of Displacement. — In the following 
case there was probably an epiphyseal disjunction. A lad four years 
old was admitted to the Hospital of the Sisters of Charity, Dec. 24, 
1849, with a simple fracture of the first phalanx of the ring finger of 
the left hand ; the fracture being at the proximal end of the bone, and 
at the junction of the epiphysis with the shaft. 



328 FRACTURES OF THE FINGERS. 

The finger was so much swollen at first, that no dressings were 
applied until the fifth day, at which time a gutta-percha splint was 
moulded to it carefully. It resulted in a perfect cure. 

I have never seen the fragments much overlapping, except in one 
instance. Frequently there has been no perceptible displacement 
whatever; but generally there will be found a slight displacement 
in the direction of the diameter of the bone. 

The case to which I refer as presenting an extraordinary overlapping, 
was that of an Irish laboring woman, aged about thirty-five years, 
who, having fallen down a flight of steps, broke the first phalanx of 
the thumb below its middle. Dr. Congar was first called on the day 
following the accident, but was unable to reduce the fracture, and on the 
same day invited me to see the patient with him. The distal fragment 
was displaced backwards, overlapping the proximal fragment a little 
more than one-quarter of an inch. We made repeated efforts, by 
pulling upon the thumb with a sliding noose, and with all the 
strength of our four hands, but to no purpose. The fragments could 
not be reduced for one moment ; and we left the patient as we had 
found her/ only somewhat the worse for our violent and repeated 
extensions and manipulations. The finger was already considerably 
swollen when we began our efforts, and we cannot therefore say what 
might have been accomplished at an earlier moment, but I confess 
that our defeat was unexpected, and does not seem to me to be satis- 
factorily explained. 

Results. — At least ten have left no appreciable lameness or deform- 
ity, and possibly several more. It is therefore probably true that 
these consequences may be avoided with proper care in one half of 
the examples in which we attempt to save the finger ; and perhaps it 
will occasion surprise that a perfect result may not be claimed in a 
larger proportion ; but when we consider how frequently the accident 
is compound, and that even when it is not, the blow having generally 
been received directly upon the point of fracture, how promptly 
swelling ensues, it will be easily understood that it will be often found 
•difficult to determine whether the bone is exactly in line or not, or to 
maintain it in this position after absolute coaptation has been once 
secured. 

I have seen the finger in two or three cases deviate laterally, or 
become permanently deflected to one side or the other ; and once I 
have found it united, but rotated on its own axis. This latter case is 
not without instruction. 

A girl, a3t. 6, had her little finger caught by a door violently shut, 
breaking one of the phalanges, and nearly severing the finger. I 
closed the wound and dressed the finger with a moulded pasteboard 
splint. My dressings were repeated often, and applied carefully ; nor 
did I detect the rotation which the lower fragment had made upon its 
own axis until the union was consummated. I then found the ex- 
tremity of the finger turned so that its palmar surface presented 
diagonally toward the ring finger. 

If the surgeon believes that this ought to have been prevented, and 
that the result evinces a lack of skill or of care, its record may still 



FRACTURES OF THE FINGERS. 329 

serve one of the purposes for which it was designed, and secure to the 
patient sometimes hereafter more faithful and assiduous attention. 

Treatment. — Boyer ; and after him Bransby Cooper, have taught that 
when the extreme phalanx is broken, from the small size of the bone, 
and from its having attached to it the nail and its matrix, it is better, 
in all cases, to amputate at once, as the process of reparation is in 
such case extremely slow and uncertain. 

Whether in any of the cases treated by myself, or which have been 
seen by me, the fracture involved the last phalanx, I am not now able 
to say, but my impression is that such cases have come under my 
notice which have been successfully treated, and I cannot but regard 
the rule established by these gentlemen as much too stringent. Ex- 
amples must, no doubt, sometimes occur, in which the fracture is so 
simple in its character as to render prompt reunion pretty certain ; 
and even though the restoration should prove tedious, this ought 
scarcely to be regarded as a sufficient justification for so serious a 
mutilation as these surgeons propose, since the loss of even an extreme 
phalanx is not only a deformity, but must prove in many occupations 
a troublesome maiming. 

Prof. J. Lizars, of the Toronto school of medicine, C. W., has re- 
ported to me a case exactly in point. " A man in the employ of the 
Toronto Boiling Mills Company fractured the distal extremity of the 
ring-finger of the right hand. The fracture was transverse, and the 
nail was severely bruised, the accident being caused by a direct blow. 
Crepitus distinct. A dorsal splint and bandage were applied, and in 
a short time the fragments were united firmly by bone. The nail 
subsequently fell off, and a new one was formed." 

The rule ought still to be held inviolate, which surgeons have so 
often repeated in reference to injuries inflicted upon the hand and 
fingers, namely, that we should save always as much as possible. 

It is remarkable, too, how much nature, assisted by art, can do 
toward the accomplishment of this purpose. If the bone of a finger 
is not only severed completely, but also all of its soft coverings, save 
only a narrow band of integument, are torn asunder, a chance remains 
for its restoration. And it is especially interesting to observe what 
recuperative powers are possessed by the articular surfaces of these 
smaller joints, so that although they may be broken into, or sawn 
through, or comminuted, and although small fragments be entirely 
removed, a complete restoration of their functions is sometimes per- 
mitted. I have seen and reported some such examples. It is true, 
however, that such fortunate results are rare, and they are rather to 
be hoped for than anticipated. 

Since, in the case of these delicate bones, the slightest deviation 
from the natural form or position determines in the end an ugly de- 
formity, it becomes exceedingly necessary, especially with females, 
that we should open and examine the fingers carefully from day to 
day, so that, as the swelling subsides, we may discover and correct 
any displacement which may happen to exist. 

As a splint, I have found nothing so convenient as gutta percha, or 
22 



330 FEACTUEES OF THE PELVIS. 

felt, moulded accurately to either the dorsal or palmar aspect of the 
finger; and the form of which I have found it generally necessary to 
change slightly every third or fourth day ; until consolidation is nearly 
or quite completed. 

If the fracture is near, or extends into a joint, the finger ought to 
be a little flexed so as to place it in the most useful position in the 
event that anchylosis should occur ; and as early as the end of the 
second week the joint surfaces should be slightly moved upon each 
other in order to the prevention of fibrous or.bony adhesions. Nor is 
there much danger of preventing the union of the bone by moving 
the joints at this early day. Union occurs between these fragments 
very speedily, and I have never met with a case of non-union of the 
phalanges, nor do I remember to have seen a case reported. 

It is the lateral inclination of the distal end of the finger which, 
according to my experience, it will be found most difficult to obviate, 
and which may, perhaps, in some cases be most successfully combated 
by laying the two adjoining sound fingers against the broken finger, 
and then applying a moulded splint to the palmar surface of the whole. 
In other cases it will be more convenient to apply the splint only to 
the broken finger. 

Eotation of the lower fragment on its own axis is especially to be 
guarded against, as the deformity which it occasions is more unseemly, 
and the impairment of utility more decided, than that occasioned by 
a lateral deviation. 

It may be well also to remind the surgeon of the convenience of 
extending the splint beyond the end of the last phalanx, and moulding 
it to this extremity, in order that the finger may be protected against 
injuries, and that when, from time to time, the splint is removed, it 
may be reapplied with accuracy. 

In all cases the splint should be lined with two or three folds of 
cotton cloth, or with a single piece of soft flannel, or patent lint, and 
secured in place with narrow and neatly cut cotton rollers. Bandages 
of this width should never be torn, but carefully cut with scissors. 



CHAPTEE XXVII. 

FRACTURES OF THE PELVIS, AND TRAUMATIC 
SEPARATIONS OF ITS SYMPHYSES. 

Development of the Os Innominatum. — This bone is formed from 
eight centres, three of which are called primary, and five secondary. 
The three primary centres belong respectively to the ilium, ischium, 
and pubes, and by their extension form eventually the greater portion 
of the innominatum. They have a common point of union in the 
acetabulum ; and the ischium unites with the pubes. also, by the June- 



PUBES. 



331 



tion of their rami. These conjunctions occur usually between the 
fifteenth and twentieth years of life. The secondary centres do not 
"begin to ossify until the* age of puberty, and may therefore properly 
be considered as epiphyses. One forms the crest of the ilium ; one 



Fig. 100. 



C-r 




Development of the os innominatum. (From Gray.) 



its anterior inferior spinous process; one forms the symphysis pubis; 
one the tuberosity of the ischium ; while the fifth constitutes the centre 
of the bottom of the acetabulum. The epiphyses become joined to 
the primary bones, or the bodies of the innominata, at about the 
twenty-fifth year. 

§ 1. PUBES. 

Lente, in his reports from the New York Hospital, mentions the 
case of a young man, set. 18, who was crushed between a couple of 
cars, in consequence of which he died two days after. The autopsy 
disclosed a separation at the symphysis pubis, unaccompanied with 
any other fracture. The right side was displaced backwards about 
half an inch, so that the fingers could be passed between the bones. 
There was also a wound in the top of the bladder large enough to 
admit the thumb. 1 Similar accidents have been several times met with 



Lente, New York Journ. Med., 2d ser., vol. iv. p. 2S6. 



332 FRACTURES OF THE PELVIS. 

by surgeons. Hall reports a case in the Provincial Medical and Surgi- 
cal Journal, May 1, 1844:, in which the pubes, thus separated, was 
actually thrust into the bladder; but in this example the ilium was 
broken also. I need scarcely add that this patient died; 1 but Sir 
Astley Cooper has furnished us with an example of a simple fracture 
or traumatic separation at the symphysis, from which the patient after 
a long time almost completely recovered. The following is Sir Astley's 
account of the case: — 

" Case 79. Eichard AVhite, set. 22, was admitted into Guy's Hospital 
on the 30th of July, 1832, having sustained a severe injury in conse- 
quence of a large quantity of gravel having fallen upon his back while 
in the act of stooping. It knocked him down ; and on rising, which 
he did with considerable difficulty, he attempted to walk ; this pro- 
duced violent pain in the region of the bladder, extending upwards 
in the course of the ureters to the kidneys. Upon inquiry, he stated 
that the urine he had voided since the accident was bloody and passed 
with difficulty. 

" On examination, a fissure was found at the symphysis pubis, pro- 
ducing a separation of about two fingers' breadth. On pressure being 
made upon any part of the ilium, he complained of increased pain in 
the region of the pubes, and of numbness down the left thigh. 

" A catheter was immediately passed, and the urine which was drawn 
off was clear and healthy. Leeches were applied over the pubes, and 
a broad belt was firmly buckled around the pelvis, sufficiently tight 
to bring the separated pubes nearly in contact, and the patient ordered 
to be kept perfectly quiet in the recumbent posture, on low diet. The 
leech-bites ulcerated, and some slight degree of fever resulted, which, 
however, readily yielded to the usual treatment. 

" He remained in the hospital for three months without any check 
to the progress of his cure; the length of time it required being 
accounted for by the difficulty of reparation in an amphiarthrodial 
articulation ; and when he left there was some slight separation of the 
pubes remaining ; nor were the two lower extremities, or the anterior 
and superior spinous processes of the ilia, perfectly symmetrical, 
although he could walk very well." 2 

Malgaigne has collected four cases of simple separations at the sym- 
physis pubis occasioned by external violence, and in three of the four 
cases it was occasioned by pressing out the thighs with great force ; 
the separation being directly due, therefore, to muscular action. 

Two of these patients succumbed to the accidents. The same author 
has brought together, also, seventeen cases of separations of this sym- 
physis occurring in childbirth, of which only seven survived. 

It is much more common, however, to find the pubes broken through 
its horizontal or ascending ramus ; and Clark, of the Massachusetts 
General Hospital, has described a case of simultaneous fracture of the 
pubes and ischium in three places. The man, set. 29, had been caught 

1 Hall, Amer. Journ. Med. Sci., vol. xxxiv. p. 248. 

2 Sir Astley Cooper, Frae. and Disloc, Amer. ed., p. 144. 



PUBES. 



333 



Fig. 101. 



between two heavy timbers, and on the following day, May 7, 1852, 
be was brought to the hospital. 

ISTo crepitus could be detected, but he was nnable to lie upon the 
right side, aud the right limb was nearly paralyzed. It was evident 
that the bladder or urethra had been ruptured, and on the third day 
Dr. Clark opened the bladder through the perineum, evacuating a 
large amount of blood and urine, and affording to the patient very 
sensible relief. On the first of June, however, he died, having sur- 
vived the accident twenty-five days. 

The autopsy disclosed several fractures, all of which belonged to 
the right os innominatum. First, a fracture of the pubes near the 
symphysis ; second, a fracture near the junction of the pubes and ilium; 
third, a fracture through the ramus 
of the ischium anterior to the tube- 
rosity. 1 

Sir Astley mentions a case (Case 
83) of fracture of the " ramus of the 
pubes," unaccompanied with injury 
to the bladder or urethra, which re- 
sulted in a complete recovery ; and 
in another case (Case 84) the patient 
recovered in eight weeks, and was 
able to walk nearly as well as before ; 
but he soon after died of disease of 
the chest. The os pubis was found, 
at the autopsy, to have been broken 
in three places; there was also a 
fracture extending in two directions 
through the acetabulum, with an 
extensive comminuted fracture of 
the ilium, accompanied with great 
displacement. 

Marat has even found it necessary, after a fracture, to remove nearly 
the whole of the body of the pubes by incision, in a girl of 18 years, 
and who not only recovered completely, but having subsequently 
married, she gave birth to two children in easy and natural labors. 2 

Cappelletti relates that a man, get. 54, jumped from a carriage, the 
horses having run away, and alighted with his feet to the ground, but 
with one limb in the greatest possible degree of abduction. A surgeon, 
who saw him immediately, found an enormous swelling at the superior 
part of the thigh, accompanied with very acute pain. When seen by 
Cappelletti, at Trieste, six months after, there still remained a slight 
swelling near the ramus of the ischium and pubes, under which a 
careful examination detected a fragment of bone two and a half inches 
long, and of the " size of the finger." The patient was able to walk, 
but not without pain and limping. Cappelletti soon began to suspect 
that this fragment of bone consisted of a part of the ramus of the 




Clark's case of fracture of the pelvis. 



1 Clark, Boston Med. and Surg. Journ., vol. liii. p. 1S5. 

2 Marat, from Malgaigne, op. oit. p. 64i5. 



334 FRACTURES OF THE PELVIS. 

ischium and pubes detached by muscular contraction. On examining 
it anteriorly he found this part of the pelvis defective, and the loose 
portion of bone had all of the anatomical characters of the defective 
part. He felt distinctly the circular projection indicating the point 
\vhere the ascending branch of the ischium unites with the descending 
branch of the pubes. 1 

Whitaker, of Lewistown, 1ST. Y. ; saw the body of the left os pubis 
broken in a female while in the seventh month of pregnancy. She 
had fallen down a pair of stairs, striking astride the edge of an open, 
upright barrel. The fracture was oblique, and with but little dis- 
placement, yet she complained of excruciating pain in the left pubic 
region on the least motion. The accident was followed by no positive 
attempt at miscarriage. 2 

The danger in these accidents consists not so much in the fracture, 
as in the injury done to the bladder and other pelvic viscera. If the 
bladder is opened into the peritoneal cavity, death is almost inevi- 
table, and even when the bladder or urethra has suffered laceration 
lower down or at any point above the deep perineal fascia, extensive 
urinary infiltrations, followed by abscesses and gangrene, generally 
expose these patients to the most imminent hazards. 

The practice pursued at Guy's Hospital in the case of separation at 
the symphysis pubis, commends itself both by its simplicity and by 
its success. Antiphlogistic remedies steadily pursued, rest in the re- 
cumbent posture, the use of the catheter when necessary, and in certain 
cases the girding the pelvis with a firm belt or band, are measures 
which seem to meet all of the important indications. 

If the fracture is accompanied with displacement, it will be proper 
to attempt to restore the fragments, but except in the case of separa- 
tion at the symphysis very little aid can be expected from a band or 
any similar means, in retaining them in place. It will be sufficient, 
generally, in such examples to place the patient quietly upon his back, 
with his thighs flexed upon his body, and to treat the accident in all 
other respects as a case of inflammation. 

If the urine has become extravasated underneath the pelvic fascia, 
no time ought to be lost in opening freely through the perineum, and 
in extending the incisions, if necessary, into the urethra and bladder. 



§ 2. Ischium. 

When speaking of fractures of the pubes we have already noticed 
some examples of fractures of the ischium also ; indeed, it is seldom 
that one of the bones of the innominatum is broken without a coincident 
fracture of one or both of the others. The records of surgery furnish 
several other examples, produced generally by a fall upon the tubero- 
sities ; but, perhaps, the most remarkable instance is that mentioned 
by Marat as having occurred in a female during labor. 

1 Cappelletti, Ranking's Abstract, No. viii. p. 83 ; from Giornale per servire al Pro- 
gressi della Patologie della Terapeutica, 1847. 

2 Whitaker. Amer. Journ. Med. Sci., July, 1857, p. 283. 



ischium. 335 

The following summary of a case of fracture of the ischium, reported 
by Sir Astley Cooper, will serve to illustrate one of the most fortunate 
terminations of these accidents when accompanied with a rupture of 
the urethra : — 

A young man who was driving a cart, was thrown down and a 
wheel passed over him. On the following morning he was found to 
have a fracture of the left leg and a contusion of the inner side of the 
left thigh. There was also great swelling and ecchymosis of the 
scrotum, with a slight appearance of injury over the pubes and left 
hypochondrium. No fracture of the pelvis was at that time discovered. 
The patient was suffering great pain, and was cold and exhausted. 
Bloody urine escaped from the bladder. On the eighth day an abscess 
had pointed on the left side of the perineum, which, being opened, 
discharged a great quantity of pus having the odor of urine; extensive 
sloughing occurred, and the patient sank very low. On introducing 
the finger into the wound, the ascending ramus of the ischium could 
be distinctly felt, and the fracture traced in an oblique course, the 
upper fragment being slightly displaced forwards. When the catheter 
was introduced into the urethra it was found to enter this wound, and 
could be felt resting against the naked bone. From this time until 
the twenty-sixth day, the urine continued to escape freely through the 
wound. In about six weeks more the fistulous opening had entirely 
closed, and after several months his recovery was complete. 1 

The signs of this accident are generally even more obscure than 
those of fracture of the pubes, but in a case of doubt the bones ought 
not only to be carefully examined from without, but the finger should 
be introduced freely into the rectum and the anterior surface explored ; 
or the tuber ischii may be grasped betw r een the thumb and finger and 
moved laterally in order to determine the existence of motion or crepi- 
tus. If the patient is a female, this exploration can be best made 
through the vagina. By flexing and extending the thigh, also, crepi- 
tus may sometimes be discovered. The examination will generally 
be made while the patient lies upon his back, but if turning is not 
found too painful, it will be well to lay him upon his face, that the 
tuberosities of the ischium may be more plainly brought into view. 

A considerable proportion of the fractures of both the pubes and 
the ischium are accompanied with lesions of the bladder or of the 
urethra, either of which circumstances will render the prognosis very 
unfavorable; but in simple fractures recoveries may generally be 
expected, yet only after a tedious confinement. 

It is not usual, except in cases which must almost necessarily prove 
fatal, to find much displacement of the fragments; nor is it probable 
that by any manoeuvres the slight displacements which are found to 
exist can be entirely overcome. Instances may occur, however, in 
which careful pressure from without, or the introduction of a finger 
into the rectum or vagina, may aid in the restoration. 

The posture best suited to these cases will be indicated usually by 
the sensations of the patient himself. Ordinarily he will prefer to lie 

1 A. Cooper, by Bransby Cooper, Amer. ed., p. 140. 



336 FEACTUEES OF THE PELYIS. 

upon his back with his thighs flexed and supported by pillows ; and 
his hips slightly elevated by a firm cushion laid under the upper part 
of the sacrum. His knees ought also to be gently bound together ; 
but if the patient finds this position painful or excessively irksome, 
as sometimes he will, he may be permitted to occupy any position 
which he finds most comfortable. 



§ 3. Ilium. 

Fractures of the ilium are much more common than fractures of 
either the ischium or pubes, and they assume a great variety of forms, 
directions, and degrees of complication. 

In the two following examples the anterior superior spinous process 
alone was broken off: — 

John Kelly, set. 36, admitted to the Hospital of the Sisters of Charity, 
Dec. 28, 1852, having just fallen and broken the anterior superior 
spinous process of the ilium. The fragment was displaced downwards 
about one-quarter of an inch. Motion and crepitus distinct. A slight 
ecchymosis existed over the point of fracture, and other signs of con- 
tusion about the hip were present. He was intoxicated at the time of 
the accident, and could not tell how or where he fell. 

He was laid upon his back in bed, with his thighs flexed upon his 
body ; and in this position we attempted to reduce the fragment and 
retain it in place with a bandage, but finding this impossible, we left 
him with only instructions to remain quietly in bed. In about two 
weeks the fragment was firmly fixed in its new position, and he was 
allowed to get up and walk about, which he was able to do without 
inconvenience. 

July 13, 1853, Matthias Morrison was caught under a bank of falling 
earth, and on the following day Dr. Mixer, his attending surgeon, 
requested me to see the case with him. He was unable to stand upon 
his feet. There was a lacerated wound and an extensive bruise on 
his left hip; but the thigh was not shortened nor everted, and he could 
flex it slightly upon his body. Noticing a swelling and discoloration 
in the region of the anterior superior spinous process of the ilium, I 
pressed upon it and felt it recede with a distinct crepitus ; the frag- 
ment, however, immediately resumed its place when the pressure was 
removed. I was able also, by a careful manipulation, to trace the line 
of fracture, and to determine that it included a small portion of the 
anterior extremity and wing of the pelvis. 

~We directed the patient to remain quietly upon his bed with his 
legs drawn up. He soon recovered, but I am unable to say what is 
the present position of the fragment. 

More frequently, however, the fracture involves a still larger por- 
tion of the crest, as in the following examples : — 

Joseph Joquoy, set. 40, was caught by the bumpers between two 
cars, Feb. 10, 1854, breaking obliquely the anterior superior portion 
of the ilium. I saw him within an hour, and found him greatly pros- 
trated; the fragment of the pelvis broken off was quite movable, and 



ilium. 337 

crepitus was easily detected. His abdomen was very tender and 
slightly bloated. 

He was laid upon his back with his legs drawn up, and hot fomenta- 
tions of hops and vinegar were directed to be applied to his belly. 
He took also one grain of morphine. The broken ala did not seem 
disposed to become displaced. With no other treatment, his recovery 
was rapid; and the bones seemed to have united without displace- 
ment. 

James Roche, set. 41, fell, March 7, 1854, from a height of fourteen 
feet, breaking off the anterior superior portion of the right ala of the 
pelvis. On the following clay, I found him at the Hospital of the 
Sisters of Charity. The fragment, which was quite large, was mova- 
ble, and occasionally a crepitus could be detected. It was displaced 
downwards and forwards about three-quarters of an inch. 

He was laid upon his back, with his thighs and legs moderately 
flexed. At the end of two weeks he found himself able to walk with- 
out much difficulty, and he immediately left the hospital. At this 
time the fragment was displaced in the same manner and direction as 
at first, but I cannot say whether it had united or not. 

I have once seen a fracture of the posterior superior spinous pro- 
cess, and I do not know of any other example. 

Miss B., get. 19, was thrown from her horse backwards, striking with 
her back upon the ground. She was first attended by Dr. Coan, of 
Ovid, N. Y. ; and she did not come under my care until two weeks 
after the accident. 

I found a small fragment broken from the posterior superior spinous 
process of the ilium, and displaced backwards in the direction of the 
spine about half an inch. It was movable, and by pressure it could 
be partially restored to place, but it would immediately return to its 
abnormal position when the pressure was removed. The injured hip 
was painful, and occasionally it felt numb. She had previously suf- 
fered from spinal irritation. 

I laid a compress behind the fragment, and secured it in place with 
a roller, enjoining perfect rest. She recovered from her lameness in 
a few weeks, but I believe the fragment remains displaced. 

Extensive comminuted fractures of the ilium are generally accom- 
panied with so much injury of the pelvic viscera as to prove rapidly 
fatal ; but the following example will show that this rule admits of 
exceptions. 

June 5, 1854, Bernard Duffle, set. 32, was crushed under a very 
heavy stone which fell upon his back. I found the left ala of the 
pelvis broken into several fragments, between the different portions of 
which motion and crepitus were distinct. The fractures were near the 
superior part of the bone, commencing about two inches back of the 
anterior superior spinous process, and extending backwards irregu- 
larly. There was a narrow wound communicating with the fracture, 
from which I removed a ,loose fragment of bone. The right leg was 
also broken. 

Four months after, he was still confined to his bed, and a fistulous 
opening continued opposite the point of fracture ; there existed also a 



668 FRACTURES OF THE PELVIS. 

large and irregular mass of ossiflc matter or callus around the frag- 
ments. He soon after left the hospital. 

Dr. Sargent, of the Massachusetts General Hospital, has reported a 
case in which a man received a compound fracture of the left ilium, 
and several small fragments were removed. He was discharged at 
the end of three months with a fistulous opening still remaining, but 
in other respects he was quite well. 1 Dr. Cheever, of the same hos- 
pital, reports a case of fracture of the ilium, with fracture of the as- 
cending ramus.of the pubes, resulting in complete recovery; but the 
leg became shortened and the toes inverted. Dr. Cheever believes 
that the lines of fracture met in the acetabulum. 2 

The following case illustrates the more fatal injuries of this cha- 
racter : — 

John O'Keaf was crushed under a heavy stone, Oct. 23, 1851, break- 
ing and comminuting the alas of the pelvis on both sides, and wound- 
ing also the iliac vein. He was taken to the Hospital of the Sisters 
of Charity, and died in a few hours, partly from the shock to his sys- 
tem and partly from the hemorrhage. 

Lente, of the New York Hospital, has reported a case of dislocation 
of the hip, which was accompanied with a fracture also of the ala of 
the pelvis upon the same side. The dislocation was reduced on the 
third day, and the patient soon after died. The autopsy disclosed 
what had not been suspected during life, namely, that the left ilium 
was broken horizontally about through its middle, and vertically 
through the crest ; and also that there was a fracture extending through 
the sacro-iliac synchondrosis, accompanied with considerable commi- 
nution of the articular surfaces. It was also found that a portion of 
the small intestine was ruptured, and probably by one of the sharp 
fragments of the broken pelvis. 3 

It is seldom, I think, that the fragments become much displaced ; 
such, at least, has been my experience; and I have noticed in Dr. 
Neill's cabinet three specimens of fracture of the crest of the ilium, all 
of which had united without any appreciable displacement. Dr. Neill 
also called my attention to the fact that in two of these specimens the 
ensheathing callus was confined to the outer surface of the bone ; an 
observation which this gentleman assures me he has had frequent 
occasion to make before where the fracture belonged to a flat bone. 

The same cabinet contains a specimen of gunshot fracture of the 
ilium, the ala being perforated by a smooth, round hole, about one 
inch below the crest. 

If any displacement exists, the upper or loose fragment is generally 
carried slightly inwards ; occasionally, however, it is found displaced 
upwards, outwards, or downwards. 

Treatment. — In a large majority of cases the fragments, if displaced, 
cannot be replaced. Occasionally, however, as where the anterior 
superior spinous process is broken off with only a small portion of the 
crest, the fragment may be seized with the fingers and carried outwards 

1 Sargent, Boston Med. and Surg. Journ., vol. liii. p. 121. 

2 Cheever, Bost. Med. and Surg. Journ., May 3, 1866. 

3 Lente, New York Journ. of Med., Jan. 1851, p. 29. 



ACETABULUM. 339 

or upwards, or in whatever direction may be necessary; but to retain 
it in this position is generally quite impossible. The bandage or 
broad belt which we have recommended in certain fractures of the 
pubes would be in these cases not only useless, but absolutely mis- 
chievous, since its effect must be to press inwards the fragments, and 
thus to create a displacement which might not otherwise exist. 

The surgeon ought to determine by a careful examination the extent 
and direction of the fracture, and, having done what was in his power 
to replace the fragments, he should lay his patient upon his back with 
the thighs drawn up and supported. This is the position which will 
generally be found most comfortable ; but, as in other fractures of the 
pelvis, it may be well always to try the effect of other positions, and 
especially to determine their influence upon the fragments, and finally 
to adopt that precise posture which, accomplishes the indications best. 

If the fracture is compound, and the fragments have penetrated the 
belly, the wound should be enlarged, and, as far as possible, every piece 
of bone should be removed; but if the fragments cannot be found, 
the external opening should be allowed to remain so as to favor their 
escape when suppuration shall have taken place. 



§ 4. Acetabulum. 

Although, strictly speaking, fractures of the acetabulum belong 
always to one or all of those bones of the pelvis whose lesions have 
already been described, yet the peculiar relations of this cavity to the 
femur render it necessary that they should be considered as a separate 
class of accidents. 

Fractures of the acetabulum divide themselves naturally into two 
varieties. 

First, Fractures of the base of the cavity, with or without displace- 
ment. 

Second, Fractures of the rim, with or without displacement. 

In fractures of the base of the cavity, not accompanied with displace- 
ment, nothing but crepitus can be present as a sign of the accident ; 
and this will scarcely be sufficient, in itself, to enable the surgeon to 
distinguish it from a fracture of the neck of the femur within the 
capsule without displacement. 

It is probable, therefore, that its existence will only be determined 
by dissection. Nor is it of much importance that the diagnosis should 
be made out ; since in either case neither splints nor any other sur- 
gical appliances could be of service. An injury so severe as to frac- 
ture the acetabulum will necessarily so much, bruise the body, and 
concuss the viscera of the pelvis, as to compel the patient to remain 
quiet for a number of days, and this is all that would be thought 
necessary if the nature of the accident was exactly determined. 

Dr. Weill's cabinet contains a specimen of this kind, in which the 
fracture, commencing near the centre, extends in three directions 
across the cotyloid margins ; and in which perfect bony union has 
occurred without displacement. 



34:0 FEACTUEES OF THE PELVIS. 

M. Bouvier related to the Academy the case of a man, set. 71, who, 
in consequence of a fall from his bed, remained for three weeks unable 
to walk, and never was able afterwards to walk without crutches. No 
fracture could be discovered during life, but after his death, which 
occurred some months subsequent to the accident, a fracture was 
found extending from the ilio-pectineal eminence to the spine of the 
ischium, and traversing the centre of the acetabulum. The fragments 
were not displaced, but remained slightly movable. 1 

The following case was reported by Mr. Earle, to the London 
Medico-Chirurgical Society, and will be found in the nineteenth 
volume of its Transactions. It is also referred to by Sir Astley, in 
his Treatise on Fractures and Dislocations. 

In the month of October, 1829, a man, set. 40, was admitted into 
St. Bartholomew's Hospital, with a severe injury caused by having 
fallen from a height of thirty-one feet and striking upon the left side. 
The left leg was powerless, and shortened. The foot was everted. 
Any attempt to rotate the limb caused great pain, and was accom- 
panied with a sensible crepitus. The left trochanter was very much 
depressed, and when it was pressed upon the patient complained of 
deep-seated pain in the hip-joint. 

He recovered in eight weeks, and was able to walk nearly as well 
as before ; but he soon after died of disease in the chest. 

On dissection, a fracture was found extending in two directions 
through the acetabulum ; there was an extensive comminuted fracture 
of the ilium, with great displacement, and the os pubis was broken in 
three places. 

The repair was very complete, and Mr. Earle remarked how nature 
had guarded against any considerable deposit of new bone within the 
articulation, which might have interfered with the functions of the 
joint, while there was an abundant deposit of callus around the other 
parts of the fractured bone. 

Mr. Travers has reported two similar cases, and in the paper accom- 
panying the report he maintains, that very acute pain caused by press- 
ing upon the projecting spine of the os pubis, and the inability of the 
patient to maintain the erect posture, may be regarded as signs 
diagnostic of the accident. 2 It is doubtful, however, whether these 
phenomena, so common to many other accidents, could be relied upon 
as evidence of this peculiar lesion. 

Fractures of the base of the acetabulum, with displacement of the 
femur into the pelvic cavity, constitute a much more formidable, and 
unfortunately a more common form of accident. 

Like the preceding variety of acetabular fractures, they are pro- 
duced generally by falls upon the trochanter major, but the force of 
the concussion has been greater. 

Even here, it is not often that the diagnosis has been clearly made 
out during life ; and indeed, generally, the true character of the acci- 

1 Bouvier, Amer. Journ. Med. Sci., vol. xxiii. p. 486 ; from Bullet, de l'Acad. Roy. 
de Med., August 15, 1838. 

2 Travers, Holmes' System of Surgery, vol. ii. p. 478. 



BASE OF THE ACETABULUM. 341 

dent has not even been suspected, the surgeons believing that they 
had to do with a fracture of the neck of the femur, or with a disloca- 
tion. In two examples (Cases 71 and 72) mentioned by Sir Astley 
Cooper as having been presented at St. Thomas's Hospital, the thigh 
was thought to be dislocated backwards. 

In the following example reported by Lendrick, of Dublin, the 
patient was supposed to have a fracture of the neck of the femur : — 

An old man, well known as the "Wandering Piper," was admitted 
into the Mercer Hospital in January, 1839, suffering under phthisis 
pulmonalis and acute inflammation of the hip-joint. Some years 
before, he had received a severe injury by the upsetting of a coach, 
and was under treatment several months for what was supposed to be 
a fracture of the neck of the femur. Since that time he had been 
lame, but still able to take a great deal of exercise on foot both in 
Great Britain and in America. The acute disease of the joint com- 
menced about two months before his admission, and he was at first 
under the care of Sir Philip Crampton, who remarked that the thigh 
was only shortened about half an inch, and expressed his surprise at 
this fact. 

This man died on the 17th of February, and the dissection showed 
that there had been no fracture of the femur, but its head and neck 
were affected with " morbus coxse senilis." The head was also thrust 
through a rent in the acetabulum into the cavity of the pelvis; but 
the head had again been covered by a bony case, complete, except in 
a small portion about the size of a shilling piece, and at this point the 
covering was ligamentous. 

The os pubis had also been broken at the same time, and it had 
united so much overlapped that the space between the inferior ante- 
rior spinous process and the symphysis pubis was shortened nearly 
an inch. A portion of intestine was found protruding through an 
opening in the pelvis and adherent to the bone, in which situation it 
seemed to have been caught by the broken fragments and retained. 1 

Morel-Lavallee, in his thesis upon complicated luxations, mentions 
a case which had come under his observation, and which had been 
treated as a fracture of the neck of the femur. The patient survived 
the accident many years; during a part of which time he suffered 
such pain in the hip-joint as to induce a belief that it was itself 
diseased. At his death he was found to have had a multiple fracture 
of the bones of the pelvis, and the head of the femur had penetrated 
more than an inch into the cavity of the pelvis, pressing upon the 
obturator nerve to such a degree as to have, no doubt, caused the 
severe pain from which he had suffered, and which had been ascribed 
to coxalgia. 2 

In the two cases mentioned by Sir Astley, as having been received 
into St. Thomas's Hospital, the toes were turned in. In the example 
mentioned by the same author as having been presented at St. Bar- 

1 Lendrick, Amer. Journ. Med. Sci., vol. xxiv. p. 481 ; August, 1839 ; from Loudon 
Med. Gazette, March, 1839. 

2 Morel-Lavallee, from Malgaigne, op. cit., vol. ii. p. 881. 



342 FRACTURES OF THE PELVIS. 

tholomew's Hospital, the toes were everted ; the two persons seen by 
Lendrick and Morel-La valine were supposed before death to have had 
a fracture of the neck ; it is probable, therefore, that in both of these 
cases the toes were also everted. While Moore has dissected a subject 
whose pelvis was broken into many fragments — the left os innomina- 
tum was divided into three portions, corresponding to the three bones 
of which it was composed in infancy; the head of the femur had com- 
pletely penetrated the basin — the limb was shortened two inches, and 
in a position of slight flexion and adduction, but neither rotated out- 
wards nor inwards. 1 

There seems, therefore, to be no certain rule in relation to the posi- 
tion of the limb; but it is found to take the one position or the other, 
probably according to the direction of the force which has inflicted the 
injury, and perhaps in obedience to circumstances not always easily 
explained. 

The shortening has been observed to vary from half an inch to two 
inches or more; the trochanter is also usually driven in toward the 
pelvis. Pressure upon the trochanter occasions a deep-seated pain. 
If the limb is drawn down to the same length with the other, it im- 
mediately resumes its position when the extension is discontinued. 
Crepitus is more uniformly present than in fractures of the neck of 
the femur, and it is especially felt while the limb is being extended or 
while it is again shortening, and not so much in flexion or rotation. 

If, in addition to all of these phenomena, we learn that the accident 
has occurred from a severe blow, or a fall from a great height upon 
the trochanter ; and that the viscera of the pelvis, and especially the 
bladder, seem to have suffered considerable injury ; or if we detect at 
the same time a fracture of some other portion of the pelvis, we may 
reasonably conclude that the head of the femur has penetrated the 
acetabulum. Yet it must be confessed that no one of these symptoms 
is positively distinctive of this accident, and that they are seldom found 
sufficiently grouped to render the diagnosis certain. 

The old " Piper" mentioned by Lendrick, and the man dissected by 
Morel-Lavallee, lived many years, and managed to walk about, but 
not without considerable pain ; the other three, to whom I have 
alluded, died soon after the injuries were received. 

Some have thought of treating these cases by extension and counter- 
extension ; the latter being accomplished through the aid of a perineal 
band ; but it is not probable that after an injury of this character, any 
patient will be able to endure the requisite pressure about the peri- 
neum or groins. It will be better to lay the patient upon Daniel's 
invalid bed, or some bed similarly constructed, so that it may be con- 
verted into a double-inclined plane; allowing the knees to be sus- 
pended over the angle thus formed, in order that the weight of the 
body may have some effect to draw away the pelvis from the femur. 
Or we may adopt Buck's method, as will be described hereafter when 
treating of fractures of the femur. 

Fractures of the rim of the acetabulum have frequently been dis- 

1 Moore, Med.-Chir. Trans., vol. xxxiv. p. 107, 1851. 



KIM OF THE ACETABULUM. 343 

covered in dissections ; and the records of surgery abound with cases 
of unreduced dislocations of the femur, in which the failure to reduce 
or to retain the bone in place has been ascribed, not always with suffi- 
cient reason perhaps, to this fracture. 

Dr. M'Tyer, of the Glasgow Koyal Infirmary, published in the Glas- 
goiv Medical Journal, for February, 1830, four cases of this fracture. 

The first was that of a man, set. 27, on whose back a number of 
bricks had fallen while he had his right knee placed on the bank of a 
trench. His right leg was found shortened about one inch and a. half, 
bent, and the toes turned a little outwards. The limb could be moved 
without much difficulty, but every motion gave him pain; motion 
was also attended with crepitus. On making extension, the limb was 
easily brought to the same length with the other, but it became 
shortened again immediately when the extension was discontinued. 

The symptoms, differing but little, if at all, from those which are 
usually present in a case of fracture of the neck of the femur, led to 
the supposition that this was actually the nature of the accident. 
Subsequently, the toes became slightly turned in, but this circum- 
stance was not regarded as sufficiently distinctive to warrant a change 
in the diagnosis. 

Having succumbed to the injuries after a few days, the autopsy 
revealed a fracture extending through the bottom of the right aceta- 
bulum, and about one inch and a half of the rim at its upper and 
posterior margin completely detached, except as it was held in place 
by a portion of the capsular ligament. The head of the bone could 
be easily pushed upwards and backwards upon the dorsum, the frag- 
ment of the acetabular margin being moved aside, and swinging upon 
its fibrous attachment as upon a hinge, but resuming its place again 
perfectly when the head of the femur was restored to the socket. The 
femur was not broken. 

* In the second case the limb was found shortened, the knee slightly 
bent, and turned a little forwards and inwards, and the toes pointing 
to the tarsus of the other foot. It was thought to be a fracture also 
of the neck of the femur, but the autopsy disclosed only a fracture of 
the upper margin of the rim of the acetabulum. 

In the third case, seen only after death, the limb was not shortened 
much, but the toes were stretched downwards, and turned slightly 
inwards. It was supposed at first to be a simple dislocation, but on 
dissection the posterior and inferior margin of the acetabulum was 
found to be broken and displaced towards the coccyx, while the head 
of the femur rested upon the pyriformis muscle, over the ischiatic 
notch. 

The fourth example was found in the dissecting-room, and the his- 
tory of the case is not known. A fragment of the superior and pos- 
terior margin of the acetabulum had been broken off, and had reunited 
slightly displaced. 1 

Several other similar examples have been established by dissection, 
and we are able, therefore, to determine pretty accurately what are 

1 M'Tyer, Amer. Journ. Med. ScL, vol. viii. p. 517, Aug. 1831. 



344: FRACTURES OF THE PELVIS. 

the usual phenomena and terminations of this accident, though we are 
far from having arrived at a satisfactory means of diagnosis ; indeed, 
the accident has seldom been recognized before death. Its causes are 
generally the same with those which produce dislocations of the hip, 
but in most instances the violence has been greater than in the case 
of dislocations. 

The symptoms are, first, such as indicate a dislocation, to which 
must be added crepitus and a difficulty, if not impossibility, of retain- 
ing the head of the femur in its place when it is reduced. The crepitus 
is sometimes discovered the moment we begin to move the limb, and 
this will aid us to distinguish it from a fracture of the neck of the 
femur accompanied with much displacement, since, in the latter case, 
crepitus is not felt usually until the extension is complete, and the 
fragments are again brought into apposition. 

The majority of these accidents, either from a failure to recognize 
them, or from the impossibility of maintaining the head of the femur 
in place when once it has been reduced, have resulted in a permanent 
dislocation of the hip and a serious maiming. The following case 
was recognized and reduced, but it was found impossible to maintain 
the reduction. 

February 3, 1847, a strong German laborer was crushed under a 
mass of iron weighing several tons. Drs. Sprague and Loomis, of 
Buffalo, were called, and found the left thigh dislocated upwards and 
backwards, and by the aid of six men they succeeded in reducing it, 
the reduction being attended, as the gentlemen have informed me, with 
a slight sensation of crepitus. The legs were then laid beside each 
other, and the knees tied together, the patient lying on his back; and 
now the two limbs appeared to be of the same length. On the second 
and third days the injured limb was examined by the same gentlemen, 
and there was no displacement. On the fourth day I was invited to 
meet these gentlemen, the patient having had muscular spasms during 
the previous night, and the thigh being reluxated. I found the limb 
shortened one inch and a half, adducted, and the toes turned in. We 
immediately applied the pulleys, and soon drew the trochanter down 
to a point apparently opposite the acetabulum, and a careful measure- 
ment showed that the two limbs were of the same length. The pulleys 
being removed, the leg did not draw up again, nor did the foot turn 
in, yet we had felt no sensation to indicate that the bone had slipped 
into its socket, nor had we felt crepitus. The legs and thighs were 
now laid over a double inclined plane, and well secured. He remained 
in this condition three days more, during which time Dr. Sprague saw 
him each day, and found nothing disarranged. On the night of the 
seventh day the spasms returned, and in the morning the thigh was 
displaced. The next day we again applied the pulleys, but soon 
found that the bone would not remain in place one minute after the 
pulleys were removed. 

At this time, while moderate extension was being made at the foot 
by rotating the foot inwards, we could distinctly feel a slight crepitus. 
A straight splint was applied, and as much extension made as he could 
conveniently bear, and in this condition the limb was kept several 



sacrum. 345 

weeks. Seven years after, I found the thigh still displaced upon the 
dorsum ilii. He limped badly, but he could walk fast, and perform 
as much labor as before the accident. 

In one case mentioned by Mr. Keate, the bone had become dislo- 
cated downwards, and could be felt lying against the tuber ischii, and 
the presence of a "distinct grating as of ruptured cartilage" led him 
to conclude that the cartilaginous labrum of the socket was broken 
off; but as the fracture was in the lower margin of the socket no 
difficulty was experienced in retaining the bone in position. 1 

If the diagnosis is satisfactorily made out, and upon complete re- 
duction the femur will not remain in place, the treatment ought to be 
the same as for a fracture of the thigh, except that no lateral splints 
or bandages to the thigh will be necessary. The limb ought to be 
kept drawn out to its proper length, as far as this shall be found to be 
practicable, by extending and counter-extending apparatus. A band 
around the pelvis, so adjusted as to press the head of the bone into its 
socket, may also be of service in preventing the tendency to displace- 
ment ; and in case the bone manifests little or none of this tendency, 
the hip bandage will probably alone be sufficient, yet even here no 
harm could come of applying the long straight splint and the extend- 
ing apparatus, secured moderately tight, simply as a measure of pre- 
caution. 



§ 5. Sacrum. 

Simple fractures of the sacrum, known to be exceedingly rare, 2 are 
occasioned either by such injuries as break at the same time the other 
bones of the pelvis, or by blows or falls received directly upon the 
sacrum. It may be broken at any point, and in any direction, when 
the fracture is produced by the first of this class of causes ; but if the 
fracture is the result of a fall upon the sacrum, it will generally be 
transverse, and below the sacro-iliac symphysis. The displacement in 
this latter class of cases is almost invariably the same, the coccygeal 
extremity being simply carried forwards, yet this is seldom sufficient 
to interfere in any degree with the functions of the rectum and anus ; 
but in one case seen by Bermond it nearly closed the rectum. Some- 
times, also, there is a slight lateral deviation. There is also in the 
Dupuytren museum, at Paris, a specimen in which the whole of the 
lower fragment is displaced a little forwards. 

The signs of this fracture are pain at the seat of injury, aggravated 
greatly in the attempts to flex or elevate the body, and especially in 
the efforts at defecation ; swelling and discoloration of the soft parts 
covering the sacrum ; displacement of the coccyx forwards; an angu- 
lar projection at the point of fracture, with a corresponding retiring 
angle upon the opposite side ; mobility. 

Experience has shown that where the fracture of the sacrum is 

1 Keate, Amer. Journ. of Med. Sci., vol. xvi. p. 225. 

2 Malgaigne has referred to eight cases ; and I have not been able to find a record 
of any others. 

23 



346 FRACTURES OF THE PELVIS. 

accompanied with other fractures of the pelvis, the patients seldom 
recover; and only because so extensive an injury implies usually 
great force in the cause which produced the fractures, and, of necessity, 
greater lesions among the pelvic viscera. Simple fractures, from falls 
upon the sacrum, occurring below the sacro-iliac symphysis, are 
generally followed by speedy recoveries, although the inward displace- 
ment is not often completely overcome. 

By introducing a finger into the rectum, the lower fragment can be 
easily pressed back to its natural position, but the difficulty consists 
in finding any means of retaining it there until bony union is effected. 
Judes succeeded to his satisfaction with a wooden cylinder, which he 
compelled the patient to wear forty-five days ; removing it, however, 
every third day, in order to cleanse the rectum with an enema. Ber- 
mond introduced first a linen bag, which he immediately proceeded 
to fill with lint, but during the night it became necessary to remove 
it in order to relieve the bowels of wind and stercoraceous matter. 
He now substituted a silver canula covered with a shirt, which latter 
he filled with lint in the same manner as before. This was retained 
without much inconvenience nineteen days ; having only been removed 
once during this time. The union now seemed to be firm, and the 
apparatus was removed. Plugging the rectum in this manner may be 
necessary whenever the inward inclination of the lower fragment is 
found to be considerable, but not otherwise ; ordinarily, it will be 
sufficient to lay the patient upon his back, with a firm cushion above 
the point of fracture, so as to prevent the bed from pressing in the 
lower fragment; and having emptied his rectum thoroughly by an 
enema of warm water, he should be placed under the influence of an 
opiate sufficiently to restrain the action of the bowels for several 
days, or for as long a time as may be consistent with health or com- 
fort. To the same end, also, the diet ought to be light and dry ; 
nothing should be allowed which might prove laxative. By consti- 
pating the bowels, two ends may be gained. We shall prevent that 
frequent action of the sphincters, which might tend to disturb the 
union; and the hardened faeces, by their accumulation in the rectum, 
may serve to press back the lower fragment of the sacrum, in a 
manner much more natural and quite as effective as any apparatus 
which can be contrived. 

J have already mentioned a case of separation of the bones at the 
sacro-iliac symphysis, reported by Lente, but which was accompanied 
also with a fracture of the ilium and a dislocation of the hip. Seve- 
ral other similar examples have been reported, in some of which both 
of the sacro-iliac symphyses have been separated, or displaced. Such 
accidents are the results only of great violence, and the subjects of 
them seldom recover. 

Dr. J. T. Banks, of Griffin, Ga., has reported one example of com- 
plete recovery in an adult male, in which the right sacro-iliac sym- 
physis was separated " by a blow received upon the tuberosity of the 
ischium, driving the ilium up an inch or more, causing complete 
paralysis and anaesthesia of the right leg for two or three weeks ;" 
motion of the hip caused also severe pain. No attempt was made to 



FRACTURES OF THE FEMUR. 347 

reduce the bones, but union occurred, and be gradually regained the 
use of his limb. 1 In a few instances this articulation has been known 
to give way during labor, while the symphysis pubis has suffered 
little or no diastasis; and in these cases recovery has generally taken 
place. 

In nearly all the traumatic examples reported, the diastasis has 
been accompanied with a fracture extending parallel with the margins 
of the synchondrosis ; and it is for this reason that I have preferred to 
consider these accidents as fractures, rather than as dislocations. 



§ 6. Coccyx. 

Cloquet mentions two cases as having come under his notice, one 
produced by a kick, and the other by a fall. In the latter case one 
thigh and both legs were also broken, and the coccyx having become 
carious in consequence of the fracture was gradually exfoliated. 2 

The symptoms, mode of diagnosis, and the treatment in case of a 
fracture of the coccyx will scarcely demand of us consideration after 
having treated fully of these points in their relation to fractures of 
the sacrum. 

It is more common, however, to meet with examples of separations 
of the coccyx from the sacrum, which may be regarded in some cases 
as veritable fractures, and in others as a species of luxation. 

Due to the same causes which produce fractures of the coccyx itself, 
its symptoms differ only in the increased length of the movable frag- 
ment, and its consequent greater projection in the direction of its 
displacement. If it is thrown forwards, as it usually is, the rectum 
may be almost or completely blocked up by its presence ; or, if it is 
carried backwards, its pointed extremity presses almost through the 
skin. 

Its mode of reduction and retention is the same as in fractures of 
the coccyx and sacrum. 



CHAPTEE XXVIII. 

FRACTURES OF THE FEMUR. 

Development of Femur. — The femur is formed from five centres of 
ossification; namely, one for the shaft, commencing at about the fifth 
week of foetal life; one for the lower end, including the condyles, com- 
mencing at the ninth month of foetal life ; one for the head, com- 
mencing at the end of the first year after birth ; one for the great tro- 

1 Banks, Atlanta Med. and Surg. Journ., May, 1SG6. 

2 Cloquet, art. Bassin, of Diet. 3d vol. 



348 



FRACTURES OF THE FEMUR. 



Fig. 102. 



chanter, commencing during the fourth year; and one for the lesser 
trochanter, commencing between the thirteenth and fourteenth years. 
ISTone of these epiphyses are joined to the shaft until 
after puberty, but consolidation is generally com- 
pleted at the twentieth year. The order in which 
•union occurs is exactly the reverse of the order in 
which ossification commences, the lower epiphysis 
being the first to exhibit traces of ossification, and 
the last to unite. 

Division of Fractures. — Of 156 fractures of the femur 
not including gunshot, which have come under my 
observation, 63 belong to the upper third, 67 to the 
middle third, and 26 to the lower third; or, if we 
confine our analysis to the shaft alone, 23 belong to 
the upper third, 67 to the middle, and 26 to the 
lower. 

The femur constitutes, therefore, a striking excep- 
tion to the rule which my observations have estab- 
lished, that in the case of the long bones the lower 
third is most often the seat of fracture. The femur 
is most often broken in its middle third, and gene- 
rally near the upper end of this third ; that is to say, 
above its middle. 



1. Neck of the Femur. 




Development of Femur. 
(From Gray.) 



Forty of the whole number were fractures of the 
neck, either intra or extra-capsular. The youngest 
of these patients, excepting one case of supposed epi- 
physeal separation, was thirty-nine years, the oldest 
eighty-four, and the average age was about sixty. Seventeen were 
males and twenty-three females. All were simple. Thirteen were 
believed to be without the capsule, and sixteen were believed to be 
w r ithin; the remainder were undetermined. 

Surgeons have differed in their opinions as to the relative frequency 
of fractures of the neck of the femur within or without the capsule. 
This has arisen, no doubt, in part from the difficulty and probable 
inaccuracy of many of the diagnoses. Malgaigne, who has adopted a 
mode of deciding this question which, it must be conceded, is much 
less liable to error than simple clinical observation, namely, an exa- 
mination of cabinet specimens, finds in four large collections sixty - 
pne intra-capsular fractures, and only forty-two extra-capsular. So 
that, according to his observations, they stand in the proportion of 
about three to two; the intra-capsular being the most common. On 
the contrary, Nelaton believes that extra-capsular fractures are much 
the most common, and Bonnet, of Lyons, affirms that they constitute 
the immense majority. Bonnet made four dissections, and in each 
case he found the fracture extra-capsular. This testimony, so far as 
it goes, is positive, but the number is not sufficient to establish any- 



NECK, VTITHIN' THE CAPSULE. 



349 



thing more than a probability in favor of the greater frequency of 
extra-capsular fractures. 

Clinical observations are too uncertain to be made available in so 
nice a question. Cabinet specimens may have been collected for 
a special purpose, and this is well known to have been the fact with 
the celebrated Dupuytren collection, the specimens in which constitute 
nearly one-third of the whole number referred to by Malgaigne. I 
allude to the effort which was made while the controversy was pend- 
ing between Dupuytren and Sir Astley Cooper as to the probability 
of bony union in intra-capsular fractures, to accumulate cabinet speci- 
mens of this fracture; and which effort extended itself, no doubt, both 
to London and Dublin, from which sources alone Malgaigne has 
gathered the balance of his figures. In Dr. Mutter's collection, at 
Philadelphia, I think there are only three examples of intra-capsular 
fracture, to seven extra-capsular. 

Dr. Reuben D. Mussey, of Cincinnati, has in his cabinet twelve 
examples of fractures of the neck of the femur without the capsule, 
and only ten within. 

We ought, therefore, to regard the question of relative frequency 
as still undetermined. 



(a.) Neck of the Femur within the Capsule. 



Causes. — In no other fractures do the predisposing causes play so 
important a part as in fracture of the neck of the femur, and this 
whether within or without the capsule; 
indeed, experience has shown that with- Fig- 103. 

■out the concurrence of those pathologi- 
cal changes which usually accompany 
old age, these fractures can scarcely 
occur. Sir Astley Cooper thought that 
the majority of fractures of the neck 
after the fiftieth year were intra-capsu- 
lar; but Eobert Smith has given us the 
ages of sixty persons having fractures 
of the neck of the femur, and the aver- 
age age of thirty -two in whom the 
fractures were within the capsule, is 
sixty-two years, while the average age 
of twenty-eight in whom the fractures 
were extra-capsular, is sixty-eight years. 
Malgaigne has referred to this testi- 
mony in proof of the inaccuracy of the 
opinion held by Sir Astley Cooper; but 
I trust it will not be regarded imperti- 
nent or hypercritical for us to inquire 
how Mr. Smith became possessed of the 
ages of all these persons from whom these specimens were obtained; 
for more than half of the whole number, that is, just thirty-two, have 




Fracture within the capsule. 



350 FRACTURES OF THE FEMUR. 

their ages set down in round decimals, such as 50, 60, 70, &c. ; and it 
would be easy to show by the inevitable law of chances that this 
could not possibly be a true statement. If Mr. Smith does not pre- 
tend to have given the ages with accuracy, but only to have arrived 
as near to the truth as his sources of information would permit, then 
I protest that these tables do not constitute proper evidence in rela- 
tion to this point; and until better evidence is furnished I shall con- 
tinue to think, with Sir Astley Cooper, that fractures within the cap- 
sule belong generally to an older class of subjects than fractures with- 
out the caps ale. This opinion, confirmed by my own experience, 
does not, however, as Malgaigne seems to think, imply that fractures 
within the capsule may not occasionally occur in persons much 
younger than the average limit, namely, under fifty years. 

It is also believed that intra- capsular fractures are more frequent 
in women than in men. 

The position of the neck of the femur and the great thickness of the 
muscular coverings render its fracture from a direct blow a very rare 
circumstance; indeed, it can only happen as the result of gunshot 
accidents, or other similar penetrating injuries. 

It is broken therefore usually by indirect blows, such as a fall upon 
the bottom of the foot, upon the knee, or upon the trochanter major ; 
or by muscular action alone, as has sometimes happened with very 
old people, who, in walking across the floor, have tripped upon the 
carpet, breaking the bone in the effort to sustain themselves. We 
must not always infer, however, because the patient has tripped, that 
the bone was broken by muscular action ; since it is quite as likely 
that the fall, consequent upon the tripping, has occasioned the frac- 
ture ; and we ought in such cases to make a careful examination of 
the hip over the trochanter to ascertain whether it has been bruised, 
and to interrogate the patient as to the manner of the fall. 

Eodet has attempted to show by a series of experiments made upon 
the dead subject, and by other observations, that the direction in 
which the force has acted will determine the situation and direction 
of the fracture. Thus he maintains that when the person has fallen 
upon the foot or knee, the fracture will be intra-capsular and oblique; 
that if the front of the trochanter receives the blow, the fracture will 
be intra-capsular also, but transverse ; if the back of the trochanter is 
struck, the fracture will be partly intra and partly extra-capsular ; 
and if the person falls directly upon the side or receives the blow 
fairly upon the outer side of the trochanter, the fracture will be 
entirely without the capsule. 1 

Without intending to give my unqualified assent to these proposi- 
tions so ingeniously maintained by Eodet, I am nevertheless prepared 
to admit their general accuracy ; and especially has my experience led 
me to believe that falls upon the feet or knees in most cases produce 
intra-capsular fractures, and that falls upon the outside of the hip, or 
upon the great trochanter, generally produce extra-capsular fractures. 
I have seen also the intra-capsular fracture produced by so slight a 

1 L'Experience, March 14, 1844. 



XECK, WITHIN THE CAPSULE. 



351 



cause as stepping down unexpectedly two or three inches upon an 
irregular surface. 

Pathology. — I have already, when speaking of partial fractures, 
expressed my conviction of the possibility of a partial fracture, or a 
fissure of the neck of the femur, and I have referred to the case re- 
ported by Dr. J. B. S. Jackson, of Boston, as having determined this 
question beyond all possibility of a doubt ; yet its occurrence must be 
regarded as an exceedingly rare, and, we may say, improbable event. 

It is much more common to meet with examples of complete frac- 
ture of the neck both within and without the capsule, unaccompanied 
with a rupture of either the periosteum or the reflected capsule. Such 
was the fact in eight cases examined by Colles ; in three of which, 
however, he believed the fracture not to have been complete, but 
Robert Smith thinks they were all of them examples of complete 
fracture. 1 Stanley has also related a case of complete separation of the 
bone unaccompanied with laceration or injury of either the periosteum 
or capsular ligament. This was in the person of a man aged sixty 
years, who had been knocked down in the street. On being admitted 
into St. Bartholomew's Hospital, shortly after the injury, he com- 
plained of pain in the hip, but there was neither shortening nor ever- 
sion of the limb, and its several motions could be executed with 
freedom and power. A fracture was not suspected ; but five weeks 
after this he died of inflammation of the bowels. The dissection 
showed a fracture extending through the neck, accompanied with a 
slight bloody effusion, but no displacement of the fragments or lacera- 
tion of the soft parts. 2 

In other examples the bone is not only broken but displaced to 
such an extent that the capsule is completely torn in two. 

But in a large majority of cases both the capsule and the periosteum 
are only partially torn asunder. 

The intra-capsular fracture is generally somewhat oblique, and its 
direction is usually from above downwards 
and from within outwards. Sometimes its 
direction is such as to include a portion of 
the head; occasionally it is quite trans- 
verse. In one example of an old fracture 
I have seen the ends dove-tailed upon each 
other, the fracture having a double obli- 
quity, and not admitting of displacement. 

There may occur also a species of impac- 
tion, the lower portion of the neck entering 
the cancellous structure of the head, while 
its upper portion rides upon the articular 
surface, a circumstance which is well illus- 
trated by the annexed woodcut (Fig. 104), 
copied by Mr. Smith from a specimen in 
the Dupuytren Museum at Paris; or the i mpact ea fracture within the capsule. 



Fig. 104. 




1 Colles, Dublin Hosp. Reports, vol. ii. p. 339. 

2 Stanley, Med.-Cliir. Trans., vol. xiii. 



352 FRACTUKES OF THE FEMUR. 

impaction may occur without any degree of either upward or lateral 
displacement. 

Mr. Liston says: "Even in children separation of the head of the 
bone may, on good grounds, be supposed occasionally to take place ; H1 
by which we understand him to mean that a separation of the epi- 
physis which completes the head of the femur may occur. Mr. South 
relates a case in a boy ten years of age, who had fallen out of a first 
floor window upon his left hip. The limb was slightly turned out, 
but scarcely at all shortened. The thigh could "fee readily moved 
in any direction without much pain, but on bending the limb and 
rotating it outwards, a very distinct dummy sensation was frequently 
felt, apparently within the joint, as if one articular surface had slipped 
off another. This was regarded by both Mr. South and Mr. Green as 
an example of epiphyseal separation, and he was placed upon a double 
inclined plane, but he felt so little inconvenience from it that he 
several times left his bed and walked about. We have no informa- 
tion as to the result or as to the further progress of the case. 2 

A girl, set. 18, was brought before Dr. Parker, of New York, at his 
surgical clinic, Nov. 1850, who had been injured by a fall upon a 
curbstone, when eleven years old. The accident was followed by 
suppuration and a fistulous discharge, from which, however, she finally 
recovered, but with the foot everted, and a shortening of one inch 
and a half. "Flexion and rotation of the joint occasioned no incon- 
venience." Dr. Parker thought this circumstance alone sufficient to 
distinguish it from hip disease in which anchylosis is the termination. 3 

At a meeting of the Kappa Lambda Society, held in New York, 
March 25, 18-10, Dr. Post mentioned a case which he had seen in a 
girl sixteen years old, who, in taking a slight step with a child in her 
arms, made a false movement, and feeling something give way, she 
was obliged to lean against a wall. Dr. Post saw her the next day, 
when he found the affected limb one inch shorter than the opposite 
one, movable, the toes turned outwards, no swelling, some slight pain 
at the upper part of the thigh. The trochanter major moved with the 
shaft. There was also crepitus. From the age of the patient, and the 
slight amount of violence by which the injury was produced, Dr. Post 
thought a separation of the epiphysis of the head had taken place. 
The extending apparatus was applied, but the limb remains from a 
quarter to half an inch shorter than its fellow. 4 

Aug. 14, 1865, Andrew Leroy, aet. 15, in attempting to escape from 
the House of Refuge, fell from the fourth story. On the following 
morning he was admitted into my wards, at Bellevue Hospital. I 
found his right thigh shortened three-quarters of an inch, and slightly 
abducted; toes everted. Placing him under the influence of chloro- 
form, we detected a dull crepitus in the vicinity of the joint. It was 
unlike the crepitus of broken bone. With fifteen pounds of extension 
we were able to overcome the shortening entirely, and to put the limb 

1 Liston, Elements of Surgery, Phila. ed., 1837, p. 480. 

2 South, Note to Chelius's Surgery, vol. i. p. 619. 

3 Parker. Amer. Med. Gazette, vol. i. p. 342, Nov. 30. 1850. 

4 Post, New York Journ. Med., vol. iii. p. 190, July, 1840. 



KECK, WITHIN THE CAPSULE. 353 

in position. This was maintained with Buck's apparatus. At the end 
of two weeks, however, it was ascertained to be shortened half an 
inch. Four more pounds were then added. At the close of my term 
of service, I lost sight of the boy, and have not been able therefore to 
verify my diagnosis ; but I believe it to have been a separation of the 
upper epiphysis. 

These four constitute the only examples of this accident which I 
find reported or of which I have any knowledge, and although there 
may be much reason to suppose that the diagnosis was correct in each 
instance, I cannot regard any one of them as actually proven; nor 
can I admit the accident as fairly established, or the diagnostic signs 
as being properly made out, until these important points have received 
the confirmation of at least one dissection. 

Symptoms. — Whether the limb will be shortened or not must de- 
pend upou whether the fragments have become displaced in the direc- 
tion of the axis of the shaft of the femur. It is well established that 
in this fracture the broken ends frequently remain in contact for 
several hours or days, or until the gradual contraction of the muscles 
or the weight of the body upon the limb occasions a separation, and 
that consequently there is often at first no appreciable or actual short- 
ening of the limb. To determine, however, its existence, it is not 
sufficient to lay the patient upon his back, and place the limbs beside 
each other ; we ought also to measure carefully with a tape line from 
the pelvis to the leg or foot, and from various other points, until we 
have placed this question beyond a doubt. 

If shortening occurs, it may vary from one-quarter of an inch to 
two inches, or even more ; but this extreme shortening is not reached 
usually, except after the lapse of several weeks or months, when the 
ligaments have gradually given way under the weight of the body in 
walking, or not until the neck has undergone a partial or almost 
complete absorption. 

Sir Astley Cooper has stated that a shortening to this degree may 
occur at once ; but Boyer, Earle, and others, doubt the accuracy of 
this opinion, and Robert Smith declares that he does not think the 
capsule would admit of such an amount of immediate displacement, 
unless it were extensively torn, an occurrence which he thinks very 
rare indeed.. 

With this qualification, the opinion of Mr. Smith does not differ 
from that entertained by Sir Astley, who only admits its possibility 
as a rare event ; in a large majority of cases the shortening does not 
exceed one inch. 

Crepitus, unlike shortening, is generally absent when the displace- 
ment of the fragments is complete ; but under no circumstances is it 
easily developed. When the fragments remain in apposition, and the 
femur is rotated for the purpose of moving the broken surfaces upon 
each other, the small acetabular fragment, resting in a smooth cup-like 
socket, and holding upon the opposite fragment by denticulations or 
by the untorn periosteum or capsule, glides about in obedience to the 
motions of this latter, and no crepitus can be produced. Nor is the 
difficulty rendered less by pressing firmly upon the trochanter, as 



354 FKACTUEES OF THE FEMUR. 

some surgeons have recommended, since, while this pressure tends, 
no doubt, to fasten the upper fragment in the acetabulum, it tends 
much more to fasten the broken ends together, and thus defeats the 
purpose in view. When, on the other hand, the fragments have become 
completely separated, it is almost impossible to bring them again into 
contact. The limb may, perhaps, be easily brought down to the same 
length with the other, but it must by no means be inferred that, con- 
sequently, the broken ends are in apposition. It is almost certain, 
indeed, that in its progress downwards the trochanteric fragment has 
caught upon the acetabular fragment, and pushed its floating and 
broken extremity downwards before it. Under these circumstances, 
the discovery of a crepitus must be accidental, and is scarcely to be 
looked for. Sometimes, however, we may recognize a sound not un- 
like crepitus, but less harsh, produced by the friction of the trochan- 
teric fragment against the rim of the acetabulum or dorsum of the 
ilium. 

One thing we ought never to forget, namely, that by extraordinary 
efforts to obtain a crepitus we may lacerate the capsule or produce a 
displacement of the fragments which we never can remedy, and which, 
without such unwarrantable manipulation, might never have occurred. 

Eversion of the foot is almost uniformly present in some degree, 
taking place immediately or more gradually, in proportion as the 
fragments become displaced, and the external rotators contract. The 
opposite condition or an inversion of the foot is occasionally present, 
and sometimes also the foot is neither turned in or out, but the toes 
point directly forwards. In sixty cases of fracture of the neck seen 
by Cloquet the foot was never turned in, and Boyer never met with 
such an example in all of his immense experience ; but Langstaff, 
Guthrie, Stanley, and Cruveilhier have each seen one example, and 
Eobert Smith has seen two. 1 I have myself seen one. 

The explanation of the fact that the foot is usually turned out is 
simple. It is owing in part, no doubt, to the natural position and 
form of the foot and leg, which incline them to fall outwards by their 
own weight, but mainly to the powerful action of the external rotators, 
which are so feebly antagonized upon the opposite side. But those 
rare examples of fracture of the neck of the femur both within and 
without the capsule, accompanied with a permanent or a temporary 
inversion of the foot, are of more difficult explanation ; and, indeed, a 
complete solution of this phenomenon does not seem to have been yet 
satisfactorily reached. 

Fracture of the neck of the femur within the capsule is not usually 
attended with much pain when the patient is at rest, but any attempt 
to move the limb produces intense suffering, and especially when an 
attempt is made to rotate the limb inwards, or to carry it upwards 
and inwards. 

Occasionally, also, during the first few days or hours after the 
fracture, a spasmodic action of the muscles compels the patient to cry 
out from the severity of the pain which it produces. At first, the 
sufferer is unable to indicate clearly the seat of this pain, or, perhaps, 

1 Robert Smith, op. cit., p. 25. A. Cooper by B. Cooper, op. cit., p. 151, note. 



THE CAPSULE. 355 

it is diffused and uncertain in its position, but after a time he is able 
to refer it chiefly to the region of the groin, opposite the neck of the 
bone, or to near the point of attachment of the psoas magnus and 
iliacus internus. There is also usually in this region a great degree 
of tenderness and an unusual fulness. 

If now the limb be seized, and extension gradually but firmly 
applied, it will soon be made of the same length with the opposite 
thigh ; but, the moment the extension is discontinued, the shortening 
and eversion will recur, accompanied with pain, and perhaps crepitus. 

The trochanter major is less prominent than upon the opposite side, 
and if eversion of the limb exists, the trochanter may be felt indis- 
tinctly upwards and backwards from its usual position. The patient 
having been placed under the influence of an anaesthetic, we may 
prosecute the investigation still farther, and by rotating the limb in- 
wards and outwards as far as it will admit, we shall notice that the 
trochanter describes the arc of a smaller circle than in the opposite 
limb, or that the length of its radius has been shortened. 

The patient is generally unable to move his limb, or to bear the 
least weight upon it ; but many examples are on record of persons 
who walked some distance after the fracture had taken place, the 
capsule, and perhaps also the periosteum, not being torn, and conse- 
quently the fragments not being displaced ; or, possibly, it was at first 
an impacted fracture. 

Finally, after having examined the patient as well as we are able to 
do, in the recumbent posture, if any doubt remains, and it is found 
practicable for the patient to be elevated upon his sound foot, this 
should be done. The broken limb can now be examined thoroughly 
on all sides, and a more accurate opinion formed of the amount of 
shortening and eversion. It will be especially noticed that if the 
weight of the body is allowed to rest upon the limb in the slightest 
degree, it produces insupportable pain. 

Prognosis. — The question of bony union after a complete fracture of 
the neck of the femur within the capsule, has occupied the attention 
of the ablest surgeons and pathologists for a long period ; and while 
great differences of opinion have been expressed as to the probability 
of the occurrence, and as to the value of the testimony on the one side 
or the other, very few have ventured to deny its possibility. 

Among these latter are found, however, the distinguished names of 
Cruveilhier, Colles, Lonsdale, and Bransby Cooper. It has been 
affirmed, also, that Sir Astley Cooper taught the same doctrine, but 
with how much show of reason, the following paragraphs from his 
own pen will determine : — 

" In the examinations which I have made of transverse fractures of 
the cervix femoris, entirely within the capsular ligament, I have only 
met with one in which a bony union had taken place, or which did 
not admit of a motion of one bone upon the other. To deny the pos- 
sibility of this union, and to maintain that no exception to the general 
rule can take place, would be presumptuous, especially when we con- 
sider the varieties of direction in which a fracture may occur, and the 
degree of violence by which it may have been produced. For example, 



356 FRACTURES OF THE FEMUR. 

when the fracture is through the head of the bone, with no separation 
of the fractured ends ; when the bone is broken without its periosteum 
being torn ; or, when it is broken obliquely, partly within and partly 
externally to the capsular ligament, I believe that bony union may 
take place, although at the same time I am of opinion that such a 
favorable combination of circumstances is of very rare occurrence. 
Much trouble has been taken to impress the minds of the public with 
the false idea that I have denied the possibility of union of fracture 
of the neck of the thio-h-bone, and therefore I heg- at once to be under- 
stood to contend for the principle only; that I believe the reason that 
fractures of the neck of the thigh-bone do not unite, is that the liga- 
mentous sheath and periosteum of the neck of the bone are torn 
through, that the bones are consequently drawn asunder by the mus- 
cles, and that there is a want of nourishment of the head of the bone ; 
but I can readily believe that if a fracture should happen without the 
reflected ligament being torn, that as the nutrition would continue, the 
bone might unite ; but the character of the accident would differ ; the 
nature of the injury could scarcely be discerned, and the patient's bone 
would unite with little attention on the part of the surgeon. 

"In proof of the correctness of my opinion, I enumerated, in the 
early editions of this work, forty-three specimens of this fracture, in 
different collections in London, which had not united by bone. At 
the present day these might be multiplied, were it necessary. 

" Such has been the accumulated evidence of the want of power of 
the neck of the femur to unite by bone, in my practice of forty years, 
during which period I have seen but two or three cases which mili- 
tate against this opinion, for many of the preparations which have 
been brought for my inspection as specimens of united fractures of 
this part have proved to be nothing more than the result of the 
changes concomitant with old age; and in many of them the two 
thigh-bones of the same subject had undergone the same alteration in 
texture and in form." 1 

The following passages from a communication made by Sir Astley 
to the London Medical Gazette, for the 25th of April, 1834, are equally 
pertinent: — 

"I find in a report of the Baron Dupuytren's lecture that he attri- 
butes to me the opinion that fractures of the neck of the thigh-bone, 
within the capsular ligament, not only l never unite, but that it is im- 
possible that they should unite by bone.' 

"It is quite true that, as a general principle, I believe that those 
fractures unite by ligament, and not by bone, as do those of the patella 
and olecranon. But I deny that I have ever stated the impossibility 
of their ossiflc union ; on the contrary, I have given the reason why 
they may occasionally unite by bone. 

" The following are my words : ' To deny the possibility of their 
union, and to maintain that no exception to this general rule may 
take place, would be presumptuous,' " &c. &c. 

1 Sir Astley Cooper, on Dislocations and Fractures of the Joints, edited by Bransby 
Cooper, Anier. ed., p. 156. 



NECK, WITHIN THE CAPSULE. 357 

111 conclusion, Sir Astley remarks : " I should not have given you 
this trouble, nor should I have taken it myself, but for the respect I 
bear my friend, the Baron Dupuytren; for although I have already 
submitted myself to be misrepresented by many individuals, yet I 
should be sorry to be misunderstood by so excellent a surgeon and so 
valuable a friend as Le Baron Dupuytren." 1 

What apology can now be found for a writer who, in a public 
lecture before an audience of surgeons, in London, delivered so late 
as the year 1858, uses the following language : — 

" It is well known that Sir Astley Cooper always taught the doc- 
trine that fractures of the neck of the thigh-bone were incapable of 
being repaired by osseous matter, and that in the whole course of his 
practice he had never met with a single instance, nor could he meet 
with any one who had seen a case where such an occurrence had 
happened ; and that union within the capsular ligament (when any 
such union takes place) is always by membrane. However, it appears 
that he had no sooner published the last edition of his work On Frac- 
tures and Dislocations, than Mr. Swan forwarded to him a specimen of 
the thigh-bone, in which the fracture of the neck had become reunited 
by osseous matter. Sir Astley retained the specimen until his death, 
and it appears that he never had the courage or policy to promulgate 
the discovery of the error of that doctrine which had so pervaded 
his mind, and which had misled the profession during a period of 
forty years." 2 

What pusillanimity is apparent in this repetition of a slander which 
had been refuted a hundred times by Sir Astley, but who, being now 
dead, might be assailed with impunity ! Do not those surgeons who 
listened to these ungenerous insinuations know well enough their 
falsity ? or is it possible that they derived a secret pleasure in hear- 
ing these insults cast upon one who, although he had done more than 
any other man to exalt the fame of English surgery, had, nevertheless, 
been only lately their rival, and from the shadow of whose colossal 
form they were just beginning to emerge into light ? Sir Astley, so 
far from denying, frankly admitted its possibility, and explained the 
circumstances under which he believed it might occur. The true point 
in dispute was, whether certain cabinet specimens were actually ex- 
amples of complete fractures, wholly within the capsule, united by 
bone. Some of them Sir Astley thought were only examples of 
chronic rheumatic arthritis, or of interstitial and progressive absorp- 
tion. Some were partial rather than complete fractures; others were 
partly within and partly without the capsule ; and for this he was ac- 
cused of wilful blindness or stupidity, chiefly by those who themselves 
being the owners of these rare pathological treasures, might possibly 
have felt somewhat annoyed at seeing their value thus depreciated, 
and who, no doubt, would be quite as apt to fall into blindness and 

1 See also Sir Astley's letter to Prof. Cox, written in 1835, and published in the Prov. 
Med. and Surg. Journ. for July 12, 1848, New York Journ. Med. for Sept. 184S, and 
appendix to Cooper on Dis. and Frac, Amer. ed., 1851, p. 482. 

2 Lettsomian Lectures on the Physical Constitution, Diseases, and Fractures of Bones, 
by John Bishop, F. R. S. London, 1855, p. 55. 



358 FRACTURES OF THE FEMUR. 

partisanship as Sir Astley himself. The truth is, however, that 
although the claim has been set up and stoutly maintained for more 
than thirty cabinet specimens, in one part of the world or another, a 
majority of these, including several whose claims were urged upon 
Sir Astley, have been at length declared by all parties unsatisfactory, 
or absolutely fictitious, and only a fraction of the whole number con- 
tinue to be mentioned by any surgical writer as probable examples. 1 

Robert Smith reduces the number to seven, but Malgaigne recog- 
nizes only three, namely : Swan's case, admitted by Sir Astley him- 
self; Stanley's case, and one specimen in the Dupuytren museum. In 
neither of these cases, he affirms, has the neck lost anything of its 
form or length by absorption, from which we are to infer that he 
would reject as doubtful all such specimens as had undergone these 
pathological changes. 

Indeed, I think we are not left in doubt as to Malgaigne's opinion 
upon this point. Six of the nineteen cases which I have enumerated 
are declared by him to resemble much more rachitic alterations of the 
neck than true fractures ; and yet Robert Smith admits three of the 
six as well-established examples ; but as to the precise grounds upon 
which he rejects these cases, he shall speak for himself: "And it is 
sufficient that we consider the beautiful drawings designed by Sir 
Astley Cooper, to illustrate certain varieties of the alterations, to place 
us on our guard against every pretended consolidation which presents 
itself, accompanied with a shortening and deformity of the head and 
neck. When fractures unite by bone they do not suffer such enormous 
losses of substance which it would become necessary to admit for the 
neck of the femur." 2 

A reference to Stanley's case, as reported by Robert Smith, will 
show that, contrary to Malgaigne's statement, this was also shortened 
and deformed, and that, consequently, according to his own rules of 
exclusion, it also must be rejected ; after which only two remain, 
namely Swan's case, admitted by Sir Astley himself, and No. 188 of 
the Dupuytren museum. 

I should do injustice to my own convictions, moreover, were I not 
to refer my readers to the following judicious criticism upon Mr. 
Swan's case : — 

1 The following European surgeons have claimed to have in their possession, each, 
one example: Langstaff (Med.-Chir. Trans., vol. xiii. 1827); Brulatour (Ibid., vol. xiii. 
1827) ; Stanley (Ibid., vol. xviii.) ; Swan (Swan on Diseases of Nerves, p. 304) ; Adams 
(Todd's Cyclop., p. 813) ; Jones (Med.-Chir. Trans., vol. xxiv.) ; Chorley (Amesbury 
on Frac, p. 125) ; Field (Ibid., p. 128) ; Soemmering (Chelius's Surgery by South, vol. 
i. p. 621) ; South (Ibid., p. 621). South also mentions another example as being in 
the museum of St. Bartholomew's Hospital. This is probably Jones' case, which Robert 
Smith says is preserved in this museum, and which has already been enumerated. 
Bryant (Memphis Med. Rec, vol. vi. p. 108, from British Med. Journ., March 14) ; 
Fawdington (Amer. Journ. Med. Sci., vol. xv. p. 534, from London Med. Gaz., Aug. 
16, 1834) ; Harris (Ibid., vol. xviii. p. 246, from Dublin Journ., Sept. 1835). Robert 
Hamilton says that Prof. Tilauus showed him three specimens in the museum of the 
Hospital of St. Peter, at Amsterdam (Ibid., vol. xxxi. p. 470, from Loud. Med. Graz., 
Jan. 6, 1843). Malgaigne says there are three specimens in the Dupuytren museum 
which have been described with the same interpretation. The whole number claimed 
by transatlantic surgeons is therefore nineteen. 

2 Malgaigne, Traite des Fractures et des Luxations, torn. i. p. 678. 



NECK, WITHIN" THE CAPSULE. 359 

" Mr. Smith's notes are as follows : ' Mrs. Powel, above eighty years 
of age, fell down, November 14, 1824. Sir Astley Cooper, who saw 
her soon after, believed that there was a fracture of the neck of the 
femur, although there was no appreciable shortening of the limb, and 
only a slight inclination of the toes outwards; crepitus could not be 
perceived ; the patient died about five weeks after the accident ; upon 
examination of the joint after death, the fracture was found to have 
been entirely within the capsular ligament, and the greater part of it 
was firmly united. A section was made through the fractured part, 
and a faint white line was seen in one portion of the union, but the 
rest appeared entirely of bone. The cervical ligament had not been 
injured.' (Smith, p. 59.) In this case the patient was an old lady, 
above eighty years of age, with the fracture not certainly made out ; 
there was no appreciable shortening of the limb ; no crepitus ; and 
only a slight inclination of the toes outwards. The strongest point in 
favor of there having been a fracture was the opinion of Sir Astley 
Cooper, which opinion is entitled to great weight ; but there are no 
satisfactory facts given upon which he formed that opinion. This 
slight eversion of the foot might be given by the patient to relieve 
the tension on the bruised and inflamed part. We may well query 
if the vessels of the ligamentum teres would not have shown evidences 
of having performed an increased function ? Would five weeks have 
been sufficient time for them to furnish osseous union, and resume 
their original size ? 

"Again, the old woman died in five weeks after the receipt of the 
injury. Now, it seems to us quite improbable, nay, impossible, that 
bony union of an intra-capsular fracture of the femur in an old woman, 
about eighty years of age, in whom there was not left vitality enough 
to sustain life, should take place in five weeks after the injury, in less 
time than is allowed for the ordinary union of a fracture of the shaft 
of the femur in a healthy person in the prime of life." 1 

Since writing the above, my friend, Dr. Yoss, of this city, has placed 
in my hands an elaborate paper on this subject, from the pen of Dr. 
Edward Zeis, of Dresden, and which has been translated by Dr. E. 
Newman, Prosector to Chair of Surgery, Long Island College Hos- 
pital. Dr. Zeis, after rejecting all other European specimens, claims 
that bony union has occurred within the capsule in a specimen now 
in his possession, and also in a specimen which may be found in the 
pathological cabinet of the medico-chirurgical academy of Dresden. 2 
I regret that I am not able to publish these cases at length, as well, 
also, as the able review of their claims sent to me by Dr. Newman, 
in which Dr. Newman clearly shows that Dr. Zeis has completely 
failed to establish the correctness of his opinions. There is no con- 
clusive evidence that the bones were ever broken, nor, if they were 
broken, that the fractures were entirely within the capsule. 

On this side of the Atlantic, the number of specimens for which 

1 An inaugural thesis on intra-capsular fractures of the cervix feraoris, by John 
Geo. Johnson, New York, 1857, p. 23. New York Journ. Med., 3d ser., vol. ii. p. 295. 

2 Description of two specimens of intra-capsular fracture of the neck of the femur, 
and union by callus ; by Dr. Edward Zeis, Dresden, 1864. 



360 



FEACTUEES OF THE FE^.IUE. 



the honor is claimed is nearly equal to the original number in Europe ; 
but they have not yet, all of them, been subjected to the same sifting 
process as their foreign congeners ; and it remains to be seen how 
many of them will come successfully out of a similar fifty years' 
contest. 

Three of the specimens belong to the venerable and distinguished sur- 
geon, Eeuben D. Mussey, late Professor of Surgery in the Miami Medi- 
cal College, at Cincinnati, Ohio, and whose many valuable contribu- 
tions to the science which he has so long adorned are familiar to all 
American surgeons. He has also himself furnished a complete history 
and description of the specimens, accompanied with drawings, which 
are published in the April number for 1857 of the American Journal 
of the Medical Sciences. 

The first patient was a Mr. S., set. 78, a hardy yeoman from one of 
the hilly districts of Northern New England. Wnen more than one 
hundred miles from home, his two-horse wagon was upset, and falling 
upon his hip he was so much injured as to be unable to rise. Dr. J. 
C. Dalton, of Lowell, Massachusetts, a highly distinguished gentleman, 
examined the limb, and pronounced it a fracture of the neck of -the 
thigh-bone, and accordingly he applied a modified Desault's appa- 
ratus. 

On the fourth or fifth day, contrary to the remonstrances of his 
surgeon, the man had himself, apparatus, and bed placed in a long box. 
and, the whole being laid in a country wagon, he started for home. 
On the eighteenth day of the accident, after reaching home, and while 
yet in the box and apparatus, Dr. Mussey was called to see him. On 
removing the bedclothes Dr. Mussey noticed that the foot and knee 
were turned considerably outwards. He immediately took off the 



Fig. 105. 




HHai 



Fig. 106. 






HI >■ T/t 





Left, or injured femur of Mr. S. 



Vertical section of the same. 



splint, and moved the hip-joint; finding that it gave him no pain, he 



flexed the thigh 



to a right angle with the body, and kept it a minute 



NECK, WITHIN" THE CAPSULE. 



361 



or two in that position, still occasioning no pain, but on flexing it a 
little further, he complained that it hurt him in his groin. Pressure 
with the finger at this point and behind the trochanter gave him de- 
cided uneasiness. No shortening could be detected. 

Dr. Mussey now felt so confident that the bone was not broken that 
he asked the*old gentleman if he wished to get up, and upon his reply- 
ing in the affirmative, he was helped into a chair and sat for some time. 
He also bore the weight of his body for a minute or two upon "his limb. 
From that day onward he wore no splint, and was got from his bed 
daily. In the course of four months 
the patient was able to walk with a 
cane, but he remained lame, and was 
never able again to ride on horseback 
as he had been accustomed to do. 

Dr. Dalton hearing of Dr. Mussey 's 
opinion, wrote to him that on his visit 
to the patient he found the limb not 
only everted but shortened more than 
an inch, and that he had detected cre- 
pitus. Yet this does not seem to 
have changed Dr. Mussey's belief 
that it was not broken. 

Two or three years after this the 
man died of an acute disease. Both 
thigh-bones were obtained. The 
right femur was sound (Fig. 107), 
but on being carefully cleaned the 
neck of the left femur was found 
to be shortened, so that in front 
it measured from the head to the 
inter-trochanteric line one inch and three-eighths, and behind only one- 
third of an inch, the shaft being rotated outwards. The head was 
sunk below the level of the top of the trochanter major, occasioning 
a shortening of more than half an inch. " A vertical section" (Figs. 
105, 106), says Dr. Mussey, " made by a saw, shows a consolidation of 
the fracture by a deposit of a mass as compact and white as ivory." 

" In the year 1830," he continues, " I showed this to Messrs. Koux 
and Amussat, and some other professional gentlemen in Paris; they 
regarded it as a fair specimen of bony union of intra-capsular fracture. 
In London I also showed it to Mr. Lawrence, Mr. Travers, Mr. Stanley, 
and Dr. Hodgkin, who was then Curator of the Museum at Guy's 
Hospital. These gentlemen were interested with the specimen, and 
considered it as a satisfactory example of bony union within the cap- 
sular ligament. On my presenting it for inspection to Sir Astley 
Cooper, he remarked, ' This bone never was broken.' I said, ' Sir 
Astley, please to look at the interior of the bone.' He separated the 
two halves, and said, ' This does look a little more like it, to be sure ; 
but I do not think it is wholly within the capsular ligament.' It is 
well known that Sir Astley, for some years, had taught the doctrine 
24 




Right, or sound femur of Mr. S. 



362 FRACTURES OF THE FEMUR. 

that bony union does not take place in intra-capsular fracture. His 
views, among the surgeons of Great Britain, were extensively admit- 
ted as correct." 

At Edinburgh, Dr. Mussey also showed the specimen to John 
Thompson, author of the great work on inflammation, who called it 
an example of absorption, &c, consequent upon old age, and affirmed, 
" upon his truth and honor," that it never had been broken. 

Dr. Mussey says, moreover, that the surgeons in this country, " who 
have examined these specimens, unhesitatingly pronounce this to be a 
case of union by bone of intra-capsular fracture." 

There are one or two points in this case which give it extraordinary 
claims to attention. The first circumstance is the shortening discovered 
by Dr. Dalton, and which was absent on the eighteenth day, when the 
limb was examined by Dr. Mussey. One of these two gentlemen was 
mistaken. If it had united, the bones were never completely displaced, 
and it could not have been shortened when Dr. Dalton first saw it. 
This position I need not now attempt to defend ; the testimony of 
all surgeons who have written upon this subject will warrant me in 
assuming thus much. Again, if it had been thus displaced, and Dr. 
Dalton had restored it to place, it seems impossible that, after a jour- 
ney of one hundred miles over a rough country in a wagon, on the 
eighteenth day, it should not have been again displaced and shortened, 
and especially if at this time the thigh was not only flexed to an acute 
angle upon the body, but the patient was permitted to stand upon it. 
If, however, Dr. Mussey still maintains that the limb was not shortened 
when he examined it, it remains for him to show how the bone was 
brought to position, and afterward kept in place so effectually, under 
such unfavorable circumstances ; or if he admits that the shortening 
existed at that time, but was overlooked by him, then we must inquire, 
When (subsequently, of course) was the bone set? and how does it 
happen that it has united at all? There must have been a mistake 
somewhere in relation to this matter of shortening ; and if so, with all 
my respect for Dr. Dalton, whose veracity and skill no man will dare 
to question, I am sceptical also as to the existence of crepitus. It is 
not entirely clear to me that he was not deceived. 

In the history of the case, then, we see no reliable evidence of a 
fracture either within or without the capsule, nor did Dr. Mussey be- 
fore the death of the patient. The bone itself, however, has convinced 
Dr. Mussey that it was broken within the capsule, and that it is well 
united by ossific matter. I have not seen it, and therefore am an 
incompetent judge of its value ; but I must acknowledge that neither 
the description nor the drawing furnishes me with any positive proof 
that it was 'ever broken, and still less that the fracture was wholly 
within the capsule. Sir Astley Cooper doubted whether, if it was a 
fracture at all, it was a fracture wholly within the capsule ; and I am 
willing to leave the question between these distinguished gentlemen 
as they have themselves left it, each one of whom was, in my opinion, 
equally earnest and sincere in his convictions, and each one of whom 
was equally competent to decide the point at issue. 



NECK, WITHIN" THE CAPSULE. 



363 



Fig. 108. 



Dr. Mussey's second specimen was obtained from a Mr. N., who, 
when fifty-one years old, fell, in alighting from his chaise, striking 
upon his left hip. He was unable to 
walk. Dr. Mussey saw him on the third 
day, and found him a corpulent man, 
lying with his foot everted, and the limb 
shortened from one inch to one inch and a 
third. He could extend the leg to within 
about one-third of an inch of its natural 
length, and when thus extended and ro- 
tated a distinct crepitus was produced. 
He applied Hartshorne's long splint, 
which was continued eighty-four days, 
the extension never being sufficient, 
however, to completely overcome the 
shortening. He ultimately walked with 
a cane, the shortening, which was about 
half an inch, being concealed by a high- 
heeled shoe. 

This man survived the injury twelve 
years, and eight years after his death Dr. 
Mussey obtained the specimen of injured 
bone (Fig. 108), together with its fellow (Fig. 110). The head of the 
injured bone is elongated and depressed, or flattened, the neck is very 
much shortened, and the trochanter turned back as in the first speci- 
men. A section (Fig. 109) shows a white, condensed tissue travers- 
ing the neck, near its junction with the head. 




The left, or injured femur of Mr. N. 



Fig. 109. 



Fig. 110. 




Vertical section of the injured femur of Mr. N. 




The right, or sound femur of Mr 



Mrs. Mason, set. 73, was the subject of the third accident. She was 
a small, thin woman, and had fallen upon her side. Two days after, 
Dr. Mussey saw her in consultation with his friend, Dr. Judkins. The 



364 



FRACTUEES OF THE FEMUR. 



knee and foot were a little everted, with slight shortening and tender- 
ness on pressure in the groin and behind the trochanter major. She 
was averse to the application of any kind of splint, and, being in a 
delicate state of health, she was allowed to remain upon her couch, 
with the thigh and leg somewhat flexed and supported by a pillow. 
She remained in this situation about three months, after which she 
could move with the aid of crutches. She died in a year and a half 
from the accident, worn out by age and exhaustion. 

The neck of the bone (Fig. Ill) is shortened to seven-eighths of an 
inch anteriorly, and to half an inch posteriorly. A considerable ridge 

Fig. 111. 





The right, or inj ured femur of Mrs. M. 



Vertical section of the injured femur of Mrs M. 



runs across the anterior part of the neck, between which and the head 
is an irregular superficial groove. A section of the bone (Fig. 112) 
presents "a narrow, white, eburnated line, corresponding with the 
aforesaid ridge, exhibiting a firm consolidation." 

I shall express no opinion of these two last described specimens 
further than to say that they seem to be liable to the same objections 
as several others of which I have already spoken, and that they do 
not belong to that class which has alone been accepted by Malgaigne. 

It is proper, however, to say that according to Dr. Johnson, in the 
paper already referred to, some of the surgeons who have examined 
these specimens have declared to him that they were not satisfactory. 

Says Dr. Johnson, in the same paper: — 

"In regard to the Philadelphia specimens, my only source of in- 
formation is the brief notice of them in the new work on surgery by 
Prof. H. H. Smith, of Philadelphia. His statement is as follows (page 
399): 'There is in the Wistar and Horner Museum of the University 
of Pennsylvania a femur, apparently of an old woman, in which the 
neck has been fractured near the head, yet in which complete osseous 
union, though with some degree of shortening, has taken place. I 
have, moreover, in my own cabinet a specimen in which the bone has 
been fractured through the neck near the head, the fragment having 
slid down beneath its natural position, and the fracture travelled 
obliquely down the neck, though still within the capsule, splitting it 
off in the line of the inter-trochanteric ridge. In this case, which 



THE CAPSULE. 365 

must have produced marked shortening of the limb, there is complete 
osseous union.' This report is so exceedingly brief that no inference 
can be drawn from it ; in fact, the writer does not appear to know 
whether the specimen is from a male or female. If this is true, then 
he knows nothing of the history of it. He does not give us the direc- 
tion of the fracture, or a drawing of it, or even a positive statement 
that it is entirely within the capsule. In regard to his own specimen 
he is more explicit ; he gives a drawing and shows that the fractured 
head has slipped down, and even now the line of fracture can be 
traced to the inter-trochanteric line. If this is so now, it is probable 
that the end of the fractured bone extended below the capsule in the 
first place, as in all cases of fracture, where there is not perfect coapta- 
tion, the rough points become absorbed. If we allow for this absorp- 
tion, it would make the end of .the bone below the trochanteric line a 
point without the capsule, thus excluding it from this class. If we 
adopt Prof. Smith's view, that this was entirely within, we meet with 
this objection. He states that the head of the bone has slipped down 
beneath its natural position, and the fracture has traversed it obliquely. 
This, of course, could not have been an impacted fracture, for in an 
impacted fracture we should have had the shaft of the bone driven 
into the cancellated portion of the head, not the head of the bone 
' slipping down' along the shaft. If this was a case of slipping down 
of the head, we leave Prof. Smith, of Philadelphia, to controvert the 
position taken by Mr. Smith, of Dublin, where he says that only 
impacted intra-capsular fractures can have an osseous union." 

Speaking of a specimen, also, which may be found in the Twenty- 
third Street Medical College, of New York, he says : — ■ 

" This belongs to Prof. Willard Parker, of this city. I am under 
obligations to Prof. Parker for his kindness in explaining to me the 
various points which he considers the case presents. He loaned me 
the specimen to examine at my leisure, that I might become thoroughly 
acquainted with all the facts of the case. According to the description 
of the case given by Prof. Parker, in his lecture, the patient was a 
maiden, about sixty years of age, an inmate of the almshouse of Bar- 
nard, Yt. One morning, while going out of doors, she fell, striking 
upon her hip. The doctor in attendance, who did riot pretend to be 
a surgeon, or accurate in his diagnosis, came to the conclusion that 
there was a fracture. He was of the opinion that he obtained crepitus; 
accordingly he dressed the limb with the straight splint for six weeks, 
and at the end of that time found half an inch shortening. The speci- 
men afterwards came into Prof. Parker's possession. The points Prof. 
Parker relies on to show that this was a fracture, are: 1. The supposed 
crepitus. 2. A ridge of bone along the inter-trochanteric line, termed 
the 'callus.' 3. The neck of the bone shortened on the outer side 
one-third of an inch more than on the inner side, this being accounted 
for on the supposition that it was produced by the position the limb 
was allowed to retain. 4. No such changes are to be found in the 
femur of the opposite side, which is pronounced healthy. 

"These specimens were procured four years after the injury. The 
capsule is entirely gone, and there is nothing to show positively where 



366 FRACTURES OF THE FEMUR. 

it was inserted; a line is pointed out about three lines below the so- 
called callus, as the line of insertion of the capsule. On examination 
of the interior of the specimen, there is nothing to indicate the line of 
fracture; no callus, such as is shown on internal examination of other 
fractures of long bones. 

" There is one point very marked on the inner edge of the compact 
structure of the shaft; it is what Sir Astley Cooper terms a 'buttress 
of bone' shooting up from the body into the neck and head, evidently 
as a support to the head in the new angle which it has assumed, with 
respect to the shaft. This buttress is formed apparently by the can- 
cellated structure being more compact than in other points. On com- 
paring this specimen with the femur of the well limb, a very marked 
difference is observable ; this line or buttress is stronger, better deve- 
loped, and is evidently for the purpose of giving support to the head 
of the bone in this new position. 

" The specimen is far from being satisfactory. If this rough line 
extending along the inter-trochanteric line is in reality the line of 
callus, then it is extremely probable that the fracture was partially 
extra-capsular. For if the capsule extended along the line which 
runs below this line that is pointed out as the line of fracture, then 
the insertion of the capsule must have been as low down as the middle 
of the trochanter minor, an anomaly in regard to insertion of the cap- 
sule. If this really was the line of insertion, it is extremely unfortunate 
that the capsule was not left to show where it was inserted. 

"Again, there is no callus on the inside of the bone corresponding 
to this so-called external callus, but throughout the whole line corre- 
sponding to this external ' callus' the cancellated structure is perfect. 
If it should be admitted that crepitus was here obtained, a point which 
is extremely doubtful, as we have only the opinion of a doctor who 
practised many years ago in the small town of Barnard, Yt., a town 
which now numbers less than two thousand inhabitants — if it should 
be admitted on such authority that this was a fracture — still, it is by 
no means established that this was an intra-capsular fracture, for this 
so-called callus extends along the inter-trochanteric line. The capsule 
itself is gone, so that it cannot be shown positively where it was in- 
serted, and it is probable, if there was a fracture, it was partly extra- 
capsular. 

"Again, the view which Prof. Parker takes of his specimen conflicts 
with that taken by Eobert \Y. Smith, of Dublin, on fractures of this 
class, in his work already quoted. For if there was crepitus, then 
there must have been motion of one fragment on the other ; and if 
there was motion, then the fracture was not impacted; and it is only 
this latter class which, Mr. Smith contends, can unite. My own im- 
pression is that there never was a fracture here at all. I think this is 
a case of interstitial absorption of the neck of the bone, the cause of 
this absorption being the contusion received by the fall. This view is 
sustained by analogy. Sir Astley Cooper says this is common in old 
people. ' As the shell becomes thin, ossific matter is deposited on the 
upper side of the cervix, opposite the edge of the acetabulum, and 
often a similar portion at its lower part, and thus the strength of the 



NECK, WITHIN THE CAPSULE. 367 

bone is in some degree preserved. This state of things may be fre- 
quently seen in very old persons.' 'When the absorption of the neck 
proceeds faster thaa the deposit on the surface, the bone breaks from 
the slightest cause; and this deposit wears so much the appearance of 
a united fracture, that it might be easily mistaken for it before the 
bone thus alters. We sometimes meet with a remarkable buttress 
shooting up from the shaft of the bone into its head, giving it addi- 
tional support to that which it receives from the deposit of bone on 
its external surface.' 

'■ Mr. Liston says : ' Gradual shortening of the lower extremity often 
ensues upon contusions of the hip in persons advanced in life, in con- 
sequence of interstitial absorption of the neck of the thigh-bone, and 
alteration of. the angle in which it is set upon the shaft. The head of 
the bone undergoes a change in form ; it becomes flattened and ex- 
panded, and the cotyloid cavity is made to correspond. This cause of 
lameness ought to be kept in view. The risk of its occurrence ought 
to be explained to those who have suffered injury of the hip, and, if 
possible, it must be prevented.' 

"Mr. Gulliver, in the Edinburgh Medical and Surgical Journal, No. 
128, July, 1836, et sea., has written very fully on this subject of inter- 
stitial absorption, and has adduced cases which we would copy if our 
limits would allow. He shows by his specimens that the head is en- 
larged at its lower part; that these cases may occur in young persons; 
that it is not disease of the joint, from the fact that there is no anchy- 
losis ; and that the cartilages are not involved. The cases of John 
Lynn, J. McGrath, and J. Fox, etc., are adduced, and the specimens 
preserved from autopsies. We have abundant evidence of interstitial 
absorption occurring from contusion in persons like this maiden, and 
Mr. Gulliver says this shortening may take place as rapidly as in five 
or six days. Now, Prof. Parker's specimen corresponds to the facts 
we have given. 1. There is a ridge formed along the lower part of 
the neck, as Sir Astley Cooper states occurs in these cases of interstitial 
absorption. 2. There is the buttress of bone shooting up from the 
shaft into the head as a means of support ; this is clearly shown by 
comparing the two specimens, the one from the well limb, and the 
one from the contused limb. 3. There was a contusion sufficient for 
an exciting cause. 4. This occurs in one limb, and not in the other, 
as shown in the case of J. Fox, reported by Gulliver, where one limb 
was in every respect natural, and in the other interstitial absorption 
had taken place. This, we believe, is the case in Prof. Parker's 
specimen. If this specimen is in reality a fracture, it was most pro- 
bably partly extra-capsular ; if not, it was a case of interstitial ab- 
sorption." 1 

Dr. Alden March, the distinguished Professor of Surgery in Albany 
Medical College, has permitted me to examine two specimens belonging 
to his collection, which he regards as examples of bony union within 

1 This specimen is probably the same to which Prof. Parker has made allusion in 
his notes to the fourth American edition of Samuel Cooper's First Lines of Surgery, at 
page 354 of volume second. 



368 FRACTURES OF THE FEMUR. 

the capsule. He has, however, rendered it unnecessary that I should 
describe particularly the appearances which they present, by having 
himself given an account of them, accompanied with drawings, in a 
paper entitled " Osseous Union of Intra-Capsular Fracture of the Neck 
of the Femur," published in the Transactions of the Medical Society of 
the State of New York, for the year 1858. The account of the first 
specimen is as follows : — 

" Of the two specimens here presented for examination, as examples 
of intra-capsular fracture of the femur united by bone, the smaller one, 
numbered 884, was procured in London some years since, and at that 
time was regarded by the curator of the old London Hospital Museum 
as a good specimen of fracture and bony union of the neck of the femur 
within the capsular ligament. I can give no history of the patient, or 
subject, from whom it was taken. I think it could not have belonged 
to an old person, and it is quite clear that he or she, as the case may 
be, lived long enough after the occurrence of the fracture for it to 
become thoroughly reunited by bony material. 

" The neck of the bone is very much absorbed, which will be found 
to be the case in almost all instances of intra-capsular fracture, whether 
united by bony or ligamentous material. This specimen, with several 
others of various kinds of organic change, was submitted to the ex- 
amination of an able professor of surgery, who has recently devoted 
much attention to the study of fractures, and who remarks upon it as 
follows : ' Specimen 884 is plainly enough a fracture, and I think there 
can be no doubt that on one side of the neck the fracture was within 
the capsule, but I have no means of determining whether it wavS also 
within the capsule on the opposite side, since the neck is almost com- 
pletely absorbed.' 

"On close examination," continues Dr. March, "it will be found 
that about all the part of the bone that can be called neck is connected 
with the shaft, and that the fracture appears to be nearly transverse, 
and close to the articulating or cartilaginous border of the head. It 
strikes me that it is just as clearly altogether within the capsule as it 
is a fracture." 

In defence- of the opinion already expressed by myself in relation 
to this specimen, and to which Dr. March has seen fit to refer in the 
passage above quoted, I will say, that the almost total absence of the 
neck posteriorly, where, in the natural condition of the parts, quite 
half an inch of the neck belongs outside of the capsule, renders it im- 
possible, in my opinion, to determine whether the fracture was not in 
part without the capsule. This remark will apply to all similar ex- 
amples, unless, indeed, the capsule itself remains to indicate precisely 
where this small portion of the neck belongs ; but the capsule is gone 
from this specimen, and the neck is lost posteriorly. If it is true, 
then, that the line of fracture can be shown to be close to the head of 
the bone, it is equally true that it hugs the trochanter; we have just 
as much right, therefore, to interpret its proximity to the trochanter 
in favor of an extra-capsular fracture, as has my distinguished friend 
to interpret its proximity to the head in favor of an intra-capsular 
fracture. 



NECK, WITHIN THE CAPSULE. 369 

Moreover, this specimen has never been sawn open, or subjected to 
the test of boiling, or of maceration, nor in any other way has the 
most important question of all been definitely settled, namely, whether 
the union is by bony or by fibrous tissue. 

The second specimen is described by Dr. March, much more at 
length, rendering it necessary that our own account of it should be 
somewhat condensed. 

Fred. L. fell from a shed when ten or twelve years old, and, accord- 
ing to the testimony of respectable citizens, was attended by a surgeon, 
and treated, as they think, for a fractured thigh ; but it does not ap- 
pear probable that splints were used, as a woman was known to carry 
him up and down stairs on her shoulders during the time-he was under 
the surgeon's care. It appears, also, that "immediately after getting 
about he was just about as lame, as much of a cripple, and as much 
distorted in his figure, as he was at any time previous to his death." 
He is mentioned by one of the witnesses, who knew him for many 
years after, as a "distorted cripple." Dr. March himself had known 
him twenty-five or thirty years, and describes him as a large-framed 
man, with a "peculiar" gait, "a kind of side waddle, one limb appear- 
ing to be two or three inches shorter than the other, and with the hip 
of the shortened side greatly projecting laterally." He was about 58 
years of age when he died. 

More or less of the skeleton of this man came subsequently into 
the possession of Dr. March, and he describes one of the thigh-bones 
as follows : — 

"A pretty large surface at its upper part and toward the trochanter 
major is a little flattened, and has the appearance of having been worn 
away, deprived of its cartilage, and becoming eburnated, or presenting 
at one point a porcelaneous polish." This change Dr. March regards 
as the result of interstitial and progressive absorption, aided by attri- 
tion, and as having occurred at an advanced period of life. 

On the anterior superior part of the neck is a ridge of bone, to 
which a portion of the capsular ligament remains attached. Most of 
the cartilaginous covering of the head has been either entirely re- 
moved, or very much thinned, leaving at certain points a polished 
surface. That part occupied originally by the round ligament "seems 
to have been getting into a state of ulceration." The whole head is 
depressed, and turned obliquely backwards. There is also a long 
spine or rib of bone extending upwards and inwards, which was im- 
bedded in the fibres of the psoas magnus and iliacus internus, and 
"seems to have its attachment at its base, to the point where we should 
look for a trochanter minor." 

At first Dr. March thought that the shaft of the opposite femur had 
also been broken three inches below the trochanter minor, and that 
it had united with some slight deformity. He also found the ala of 
the pelvis on the right side bent inwards, so that the distance from 
the crest to the centre of the sacrum was three-fourths of an inch less 
than on the opposite side. This, too, he ascribed at first to the original 
injury, but further investigation has satisfied him that it was due to 
the action of the muscles, and that the opposite limb had never been 
broken. 



370 FRACTURES OF THE FEMUR. 

To this description, condensed from the paper alluded to, I need 
only add, that the whole head of the bone is very much flattened and 
changed in shape, and that there is scarcely anything which can be 
appropriately called a neck. The bone has been sawed in two, but 
Dr. March does not pretend that the bisection furnishes any additional 
evidence that it had been broken. 

My objections to this case are briefly: — 

It is not satisfactorily made out that there was ever a fracture, either 
by a reference to the original history, or by an examination of the 
bone. The age at which the accident occurred (10 or 12 years) is 
presumptive evidence against a fracture of the neck' of the femur 
within the capsule, if not almost conclusive, unless it is claimed to be 
an example of epiphyseal separation with a bony union, a supposition 
which, so far as I can learn, no surgeon has yet ventured to make. 
Dupuytren says he never saw a fracture of the neck of the femur in 
a child. The youngest I have seen recorded is that mentioned by 
Sabatier, in which case the boy was fifteen years old. 1 Dupuytren 
has also well explained the causes of this infrequency of a fracture of 
the neck of the femur in early life. 

On the other hand, the age at which the accident occurred was 
favorable to the production of disease of the hip-joint. The whole 
history of the patient, from that time onwards, especially his peculiar 
"waddle," seems to indicate that his hip-joints were both diseased. 
The autopsy shows that they actually were diseased, and renders it 
quite probable also that all of the bones of his body were in an un- 
healthy condition. The specimen itself is in nearly all respects a 
counterpart of many others to be found in the museums of this and 
other countries, and which are now, by almost unanimous consent, 
declared to be examples of chronic rheumatic arthritis. 

Dr. Mutter thought also that specimen B, 71, in his collection of 
bones, now lying in the Jefferson Medical College at Philadelphia, was 
a genuine example. It is a cleaned and dried specimen, from which 
the capsule, and all the soft parts, have been removed. The neck 
is very nearly absorbed, and the trochanter major is rotated backwards, 
as we see in nearly all examples of interstitial absorption, so that it 
almost touches the head. The interior has never been exposed, to 
determine the line of the supposed fracture, nor is there anything 
upon its external surface by which this point, so essential to the ques- 
tion at issue, can be decided. It may be an example in point, but the 
proof is not before us: 

Dr. Charles A. Pope, Professor of Surgery in the St. Louis Univer- 
sity, Missouri, informs me that he has an example of " intra-capsular 
fracture of the neck of the femur, with concomitant fracture of the 
acetabulum. The union by bone is perfect, although the neck is, as 
it were, gone, the head being almost squarely set on the shaft of the 
bone. The head is much deformed, being an enlarged cone, and fit- 
ting into a similarly shaped acetabulum. The motions of the joints 
were well preserved." 

I have never seen this specimen, and I am therefore unable to speak 

1 Dupuytren on Dis. and Injuries of Bones, p. 187. 



XECK, WITHIN THE CAPSULE. 371 

of it authoritatively, but I confess I do not see how it is possible to 
know that the fracture was wholly within the capsule when the neck 
is gone. If the capsule remains attached to the specimen, it may aid 
in the elucidation of this point; but it does not appear from Dr. Pope's 
communication that such is the fact. I should be gratified if this dis- 
tinguished surgeon would give the profession a more complete account 
of the case. 

From various -sources, including several private letters, I have been 
able to gather a few of the particulars relating to a case which for 
some time attracted the attention of the profession in this country ; 
but a full account of which, I regret to say, has never been published. 1 

Somewhere about the year 1832 x Mrs. William Nelson, of Derby, 
Vt., fell, and was slightly lamed. Dr. M. F. Colby, of Stanstead, 
Lower Canada, being consulted, declared that she had broken the 
neck of the thigh-bone. She was accordingly placed in a horizontal 
position, and an extending apparatus applied. This treatment was 
continued one month, during which time she became insane; but from 
this condition she ultimately recovered. At the end of one month 
the apparatus was removed, and she was able to walk after her re- 
covery without much halt, and the limb did not seem to be much 
shortened. 

Subsequently the husband of Mrs. Nelson prosecuted Dr. Colby for 
causing insanity through unnecessary confinement, alleging that the 
bone was not broken ; and, as evidence that it was not, testimony was 
presented to show that she was able to walk a few steps immediately 
after the injury was recived; that she could draw up her legs; that 
she rode sitting upon the seat of a wagon ; that the extending splint 
was continued only four weeks, and that, although it was loosened 
occasionally by the friends, the limb did not shorten; and, finally, that 
she had a perfect, or nearly perfect, limb. 

The case remained in court several years, until both parties were 
nearly ruined ; but ten years after the accident Mrs. Nelson died, and 
both femurs, says Dr. Mussey, were secured by Dr. Colby. The one 
believed to have been broken was then sent to several of our larger 
cities, and among others it was examined by Hay ward and one of the 
Warrens in Boston ; Dixi Crosby, of Dartmouth ; Willard Parker ; 
one of the Eogerses in New York; and Kobert Nelson, of Canada. 

Eobert Nelson and Kogers still denied that it had been broken, both 
of these surgeons affirming that the bone was perfect ; but on the part 
of the defence, it was subsequently charged that a spurious bone had 
been laid before these latter gentlemen. Drs. Warren 2 and Hayward 
thought it had been a dislocation; Drs. Parker and Crosby believed it to 
have been a fracture within the capsule, and that it was united by bone. 

Dr. Mussey, to whom the specimen has been described, but who has 
never seen it himself, says that " the bone belonging to the injured 

1 Boston Med. ami Surg. Journ., Jan. 26, 1842; Amer. Journ. Med. ScL, April, 1857, 
p. 310. 

2 Dr. Mussey says, " Dr. Warren decided there had been a fracture ;" but I have it 
upon the authority of Dr. Colby that Dr. Warren had called it a dislocation, or that a 
witness so testified. Perhaps it was not the same Warren. 



372 FRACTURES OF THE. FEMUR. 

limb had a ridge across the neck, while the head was so far depressed 
as to shorten the thigh-bone three-sixteenths of an inch." 

Dr. Colby finally received a judgment in his favor for one cent costs, 
and a bond signed by the prosecuting attorney, to the effect that the 
bone, which was now in the possession of the prosecutor, should be 
given up to the defendant, and remain in his possession during a period 
of six months, in order that he might show it to the public ; but this 
part of the contract has been broken, and the bone seems now to be 
lost to science. 

Whatever may be our opinion as to the probability of the fracture 
in this case, the absurdity and cruelty of the allegation of malpractice 
is too plain to admit of discussion or a doubt among intelligent medical 
men. If Dr. Colby thought there was a fracture — and he certainly 
had reasons to think so — his treatment was such as every judicious 
surgeon would have adopted, and for not adopting which he might 
justly have been held responsible. 

I have in my cabinet a cast which I made nearly twenty years since, 
from a femur then owned by Prof. James Webster, of Eochester, late 
Professor of Anatomy in the University of Buffalo, and which he be- 
lieved to be a case of union by bone after a fracture within the capsule. 
The patient from whom this specimen was obtained was a female, and 
had been seen by him before death. Its resemblance to the specimen 
owned by Dr. March, and purchased by him in London, is so perfect, 
that I believed it to be the same, until Dr. March informed me that it 
was not. It is almost its exact counterpart, however, as I know by 
a comparison of the specimen with my own cast of Prof. Webster's. 
This fact will render it unnecessary that I should state my objections 
to it, since the same remarks will apply to it as to Dr. March's specimen. 

I have also in my own cabinet a femur of no inconsiderable preten- 
sions, belonging clearly to that class of specimens recognized by Eobert 
Smith. Its neck is greatly shortened, and this surgeon would regard 
it, I think, as an impacted intra-capsular fracture, but its claim would 
be. promptly denied by Malgaigne, on account of the absorption and 
distortion of its neck. Its history is as follows : — 

About the year 1833, Mrs. Wakelee, of Clarence, Erie County, New 
York, set. 68, who was then very low with tubercular consumption, 
and so ill as to be scarcely able to walk across the floor, tripped upon 
the carpet and fell, striking upon her left side. She was unable to 
rise, but was laid upon a bed by her son, Dr. Wakelee, a very intelli- 
gent physician, residing in the same house, who did not suspect a 
fracture. Dr. Bissel saw her on the following day, and on rotating 
the limb outwards, he says that he discovered a crepitus. His exami- 
nation was greatly facilitated by her extreme emaciation. 

Mrs. W. was placed upon a double-inclined plane, with apparatus 
for extension, &c, and left in charge of Dr. Wakelee. On the fifth 
day the splint was removed, and from this time no dressings of any 
kind were applied. The reason for this change of treatment was, that 
she was likely to live but a few days, in consequence of the state of 
her lungs, and that such confinement would only hasten her death. 
Contrary, however, to all expectations, she gradually convalesced, so 



NECK, WITHIN THE CAPSULE. 



373 



Fig. 113. 




that after two or three years she could walk on crutches, her toes turn- 
ing out and her limb becoming somewhat shortened. Four years after 
the accident she died, and Dr. Bissel obtained from Dr. Wakelee the 
specimen, of which the accompanying drawing is a faithful delineation. 

I am informed, also, that there are two 
specimens in the Boston Museums, but 
the descriptions which I have received of 
them are too imperfect to allow me to 
speak of their merits. 

Such is the present state of the testi- 
mony upon this interesting but difficult 
subject. In it all we think we see enough 
to warrant a belief that under certain 
favorable circumstances bony union may 
occur, but not enough to establish it be- 
yond all doubt. There are those who 
feel much more assured, and who are as 
confident of this fact as that the shaft of 
the femur will unite by bone ; we do not 
accuse them of credulity, and we invoke 
for ourselves the same exercise of charity 
toward our scepticism. We have never 
yet seen a specimen which, upon a care- 
ful examination, proved satisfactory ; but 
unless our want of conviction can be 
shown to be the result of a wilful blind- 
ness, we shall demand protection against 
the assaults and insinuations which have so frequently fallen upon 
those who ventured to doubt the authenticity of every specimen 
which T was laid before them. 

Within the last few years, Dr. Geo. K. Smith, of the Long Island 
College Hospital, has made a most valuable contribution to our know- 
ledge of the anatomy and pathology of the hip-joint, which will 
explain in a great measure the discrepancies of opinion which at 
present exist among surgeons as to the character of certain specimens, 
and may hereafter enable us to decide with more accuracy, and may 
lead to a better agreement of opinion. 

His observations prove that anatomists have not hitherto correctly 
described the attachment of the capsule ; that the capsule is seldom, if 
ever, attached at the same point in different persons, while it is as 
uniformly found attached at the same point in the opposite femurs of 
the same person. In order, therefore, to determine whether the line 
of fracture in any given specimen was without or within the capsule, 
we must always compare the fractured bone with its congener, and not 
with the femur of another person. 

He has further shown that after a fracture, and the consequent 
absorption of the neck, the normal position of the capsule is almost 
constantly changed ; so that its present attachment does not declare 
what were the points of its attachment before the fracture occurred, 
and finally that the absorption proceeds unequally and irregularly, 
yet with great rapidity, in the two fragments ; and as the bony union, 



Vertical section of Mrs. Wakelee 's 
femur, acetabulum, and capsule. 



374 FRACTURES OF THE FEMUR. 

if it ever takes place, probably occurs subsequent to the arrest of the 
absorption, the line of union cannot in itself alone determine whether 
the fracture was near the head or near the trochanters. 1 

I repeat that it seems to me probable that under certain favorable 
circumstances this union will occur; these favorable circumstances 
have relation to several conditions, such as age, health, degree of 
separation of the fragments, laceration of the periosteum and capsule, 
treatment, &c. Eobert Smith thinks it is not likely to occur unless 
the fragments are impacted, but Sir Astley Cooper, as we have already 
seen, admitted its possibility whenever the reflected capsule and the 
periosteum were not torn, and at the same time the fragments were 
not displaced. If to these conditions we were to add moderate but 
not extreme age, with good health, we can see no sufficient reason 
why, under judicious treatment, bony union might not occasionally 
be expected. But such a combination of circumstances is probably 
exceedingly rare: and, what is more unfortunate, if they exist, the 
fracture is not likely to be recognized, and the surgeon will fail to 
avail himself of those advantageous coincidences which might, if 
understood and properly treated, secure a bony union. Dupuytren 
says, when the fragments are not displaced "its existence may be 
suspected, but cannot be positively asserted." There will not be 
wanting, however, examples in which surgeons will believe or affirm 
that they have recognized the fracture and wrought the cure. I have 
heard of many such instances, and Mr. Smith has referred to one, 
which is quite pertinent, as having been reported in the Gazette des 
Hupitaux. A woman, set. 64 3 was treated for an intra-capsular fracture 
of the neck of the femur at one of the hospitals in Paris, and " at the 
end of four weeks she was discharged perfectly cured, and without 
shortening." TTe fully partake of Mr. Smith's surprise at the impu- 
dence of this claim, yet we do not see in it much greater improbability 
than in Mr. Swan's case, received by both Mr. Smith and Sir Astley 
himself, where the neck was found almost wholly united by bone in 
five weeks, although the woman was 80 years old, and actually dying 
while the process was going on ! Says Dupuytren, " I would lay it 
down as a general principle that all fractures of the neck of a cylin- 
drical bone should be kept at rest twice as long as ordinary fractures 
of the same bone ; and even after that period I have seen displacement 
take place. The term may, therefore, be lengthened to a hundred 
days, or even longer in aged and feeble persons, whose powers of repa- 
ration are much deteriorated. 

It is not the purpose of the writer to describe particularly all of 
the accidents or pathological conditions with which these fractures 
may be confounded. It is sufficient to allude to them, and leave to 
others the labor of a complete historical record; but I am tempted to 
devote a paragraph to what has been variously termed "morbus coxae 
senilis" (Robert S r mith); "chronic rheumatic arthritis" (Adams) ; "inter- 
stitial absorption of the neck of the thigh-bone" (B. Bell) ; and by 
others " interstitial and progressive absorption ;" but the exact nature 

1 Geo. K. Smith, Insertion of the capsular ligament of the hip-joint, and its relation 
to intra-capsular fracture. Medical and Surgical Reporter, Philadelphia, 1S62. 



NECK, WITHIN THE CAPSULE. 



375 



Fig. 114. 



and cause of which morbid changes are not yet fully understood. Mr. 
Colles does not think this partakes of the nature of rheumatism. I 
have myself a specimen of what has 
been more generally called chronic 
rheumatic arthritis, occurring in the 
knee-joint, accompanied with a flatten- 
ing and eburnation of the articular sur- 
faces, and Gulliver has shown that 
similar changes of form in the neck of 
the bone may occur in tolerably young 
persons. 

I suspect also that it will be found to 
occur under a greater variety of circum- 
stances, and to present a greater variety 
of forms than have yet been described ; 
and we shall perhaps find a partial ex- 
planation of this diversity and fre- 
quency in one single circumstance, 
namely, the peculiar anatomical struc- 
ture of the neck. The neck of the 
femur stands nearly at a right angle 
with the shaft, or at an angle so great 
as that the weight of the body, even in health, has the effect to gradu- 
ally depress the head below the top of the trochanter major, and to 
diminish its length. This is seen constantly in the striking change of 
form which occurs between childhood and old age. Now, if from any 




Section of a sound adult femur. 



Fig. 115. 




Chronic rheumatic arthritis. (Miller.) 



cause whatever, such as a blow upon the trochanter or upon the foot, 
the neck or head is made to suffer, and inflammation, or perhaps 



376 FRACTURES OF THE FEMUR. 

only a slight degree of increased action in the absorbents, ensues, 
resulting in an equally slight softening of the bony tissue, these patho- 
logical circumstances may end, sooner or later, in a striking change of 
form in the neck or head. But it is not necessary to suppose an 
external injury to explain the occurrence of this inflammation, and 
consequent softening of the bone ; a scrofulous, or rickety, or tuber- 
culous constitution may occasion it, and we see no reason why these 
conditions are not as likely to lead to a change of form here as in the 
bones of the leg or of the spine. A change of form in the head may 
be the result of an ulceration of the cartilage; and a change of form in 
the neck, of ulceration of the neck. Among other causes, also. " chronic 
rheumatic arthritis may operate in a large proportion of those examples 
which belong to advanced life. One case, reported by Gulliver, would 
seem to show that a deformity may occurr here as a result of disease, 
and independently of pressure, 1 yet it is plain, from the direction which 
the deviation of the head and neck usually takes, that pressure per- 
forms an important part in the causation. 

From these various causes, operating in these diverse ways, we shall 
have the different deformities enumerated and described by surgical 
writers. The head flattened, irregularly spread out, depressed and 
polished ; the neck shortened and irregularly thickened and expanded ; 
the trochanter major rotated outwards and drawn upwards; sinous 
chasms traversing the neck, produced by ulceration ; and finally, 
shortening of the neck, by a true interstitial absorption, and with 
little or no increase in its breadth, the trochanter major also being 
rotated outwards. It would be strange, moreover, if the interior of 
these bones did not present some changes in structure, such as have 
been frequently observed, namely, an irregular expansion or conden- 
sation of the cellular tissue, and which latter might easily be supposed, 
by one who was inattentive to all of these circumstances, to indicate 
the line of an imaginary fracture. 

The following example will illustrate the incipient stage of one class 
of these cases, namely, that in which the neck is not only shortened, 
but its surface is irregularly seamed, as if it had been broken and 
imperfectly united. 

Wm. Clarkson, set. 43, was admitted into the Toronto Hospital, C. 
"W., May 5, 1858, with tubercular consumption, of which he died on 
the 25th of the same month. 

He had been under the care of Dr. Scott, and it having been noticed 
that he complained of his right hip at the time of admission, an autopsy 
was made on the 25th, at which I was, through the courtesy of the 
house surgeon, permitted to be present. 

We examined both hip-joints, and found the neck of the right femur 
shortened, especially in its posterior aspect. At the junction of the 
head with the neck, posteriorly, and extending about half way around, 
the bone was carious, and so far absorbed as to leave a sulcus of a line 
or two in depth, and of about the same width. Adjacent to this, also, 
the bone was quite soft, yielding under the slightest pressure of the 

1 Gulliver, Lcmd. Med.-Chir. Rev., vol. xxxix. p. 544. 



THE CAPSULE. 377 

knife. There was no other appearance of disease. The opposite 
femur was sound. 

The hospital record furnished the following account of his case, so 
far as the injury to his hip was concerned: — 

About nine months before admission, then laboring under the ma- 
lady of which he finally died, he received a blow upon his right tro- 
chanter, ever since which he had been lame, and suffered pain in the 
region of the hip-joint. The pain was felt especially in the groin, when 
the trochanter was pressed upon, or when the sole of his foot was per- 
cussed. The thigh was slightly flexed ; the toes a little everted ; and 
he walked with some halt. 

The case of the soldier, Fox, reported by Gulliver, and who died of 
tuberculosis, presents a case also exactly in point, but illustrating a 
later stage, or the completion of the same process. 

Of the precise nature of the changes in the two following examples, 
I cannot be certain, since they have not been determined by dissection. 
They will serve, however, to illustrate the usual history and progress 
of a considerable number of cases. They certainly were not examples 
of fracture. 

Ephraim Brown, when twelve years old, fell from a tree and struck 
upon his right foot. Dr. Silas Holmes, of Stonington, Ct., was called. 
Of the particular symptoms at this time, I have only learned that the 
leg was not shortened. The doctor laid a plaster upon his hip, and 
left him without any further treatment. In three days he was able to 
walk on crutches ; in three weeks he walked without crutches, and in 
four months was at work as usual. There was at this time no short- 
ening or deformity of any kind. 

Mr. Brown subsequently enlisted as a soldier in the war of the 
American Eevolution, and experienced no difficulty in this hip until 
after a severe illness which followed upon an unusual exposure, when 
he was about thirty-five years old. At this period the leg began to 
shorten, but the shortening was unaccompanied with pain or soreness. 

He consulted me, July 17, 1845, at which time he was eighty-three 
years old, and a remarkably strong and healthy-looking man. The 
shortening, which had ceased to progress some years before, amounted 
at this time to two and a half inches. 

An officer in the United States army addressed to me the following 
letter, dated Nov. 13, 1849 :— 

" My mother-in-law, Mrs. S., of D., some three years since fell down 
a flight of stairs, striking on her side upon a stone, injuring the hip- 
joint severely; but, upon examination, her physician declared that 
there was neither a fracture nor a dislocation, and said that she would 
gradually recover. Something like one year since the injured limb 
commenced shortening, so that she can now barely touch her toe to 
the floor as she walks. She can bear but little weight upon it, and 
is compelled to use a crutch or a cane constantly. So much time has 
now elapsed, and the limb is so little better, and constantly becoming 
shorter, I have proposed to ask your opinion," &c. 

I need scarcely say that I had no hesitation in pronouncing this a 
25 



378 FRACTURES OF THE FEMUR. 

case of chronic inflammation of the bone, accompanied with softening 
and gradual change of form, either of the neck or head ; or of both. 

It is proper that I should state briefly, before I leave this subject, 
what constitute the chief difficulties in the way of union by bone 
within the capsule. 

The persons to whom the accident occurs are generally advanced in 
life, and consequently the process of repair is feeble and slow. 

The head of the bone receives its supply of blood chiefly through 
the neck and reflected capsule, and when both are severed, the small 
amount furnished by the round ligament is found to be insufficient. 

When the fragments are once displaced, it is difficult, as I have 
already explained, if not impossible, to replace them. 

The direction of the fracture is generally such that the ends of the 
fragments do not properly support and sustain each other when they 
are in apposition. 

The fracture is at a point where the most powerful muscles in the 
body, acting with great advantage, tend to displace the broken ends. 

Aged persons, who are chiefly the subjects of this accident, do not 
bear well the necessary confinement, and especially as the union 
requires generally a longer time than the union of any other fracture; 
so that a persistence in the attempt to confine the patient the requisite 
time often causes death. 

"Whether the absence of provisional callus as a bond of union, and 
the interposition of synovial fluid between the ends of the fragments, 
constitute additional obstacles, I am not fully prepared to say. In the 
opinion of many surgeons these circumstances constitute very serious, 
if not the chief, obstacles. 

It remains only to consider what is the usual result of this fracture. 

The fragments, more or less displaced, undergo various changes. 
The acetabular fragment is generally rapidly absorbed as far as the 
head; and occasionally a considerable portion of this latter disappears 
also ; while the trochanteric fragment appears rather as if it had been 
flattened out by pressure and friction, it having gained as much gene- 
rally in thickness as it has lost in length. To this observation, how- 
ever, there will be found many exceptions. Sometimes the trochanteric 
fragment forms an open, shallow socket, into which the acetabular 
fragment is received ; or its extremity may be irregularly convex and 
concave, to correspond with an exactly opposite condition of the ace- 
tabular fragment. (Fig. 116.) 

Ordinarily the two fragments move upon each other, without the 
intervention of any substance ; but often they become united, more or 
less completely, by fibrous bands (Fig. 117), which bands may be 
short or long, according to the amount of motion which has been 
maintained between the fragments while they are forming, or to the 
degree of separation which exists. 

The capsular ligaments are usually considerably thickened, and 
elongated in certain directions, and not unfrequently penetrated by 
spicula of bone. They are also found sometimes attached by firm 
bands to the acetabular fragment, 

A permanent shortening, either with or without eversion of the 



NECK, WITHIN THE CAPSULE. 



379 



limb, are the invariable consequences of this accident. Indeed, not a 
few succumb rapidly to the injury, perishing from a low, irritative 



Fisr. 116. 



Fig. 117. 





Fracture of cervix femoris within capsule. 
Ununited. Opposite surfaces irregularly con- 
vex and concave, and polished ; moving slightly 
upon each other. (From a specimen in the pos- 
session of Dr. Crosby.) 



Mayo's specimen. United by ligament. Patient 
lived nine months after the accident. The tro- 
chanter minor arrested the descent of the head. 
(From Sir A. Cooper.) 



fever, or from gradual exhaustion, within a month or two from the 
time of its occurrence. Says Robert Smith: "Our prognosis, in cases 
of fracture of the neck of the femur, must always be unfavorable. In 
many instances the injury soon proves fatal, and in all the functions 
of the limb are forever impaired ; no matter whether the fracture has 
taken place within or external to the capsule — whether it has united 
by ligament or bone — shortening of the limb and lameness are the 
inevitable results." 

Treatment. — In case, then, of a complete fracture within the capsule, 
existing without laceration of the reflected capsule, or displacement of 
the fragments, and equally in case of a fracture at the same point with 
impaction, the treatment ought to be directed to the, retention of the 
bone in place, by suitable mechanical means, for a length of time 
sufficient to insure bony union, or for as long a time as the condition 
of the patient will warrant. 

The means which are best calculated to fulfil this important indica- 
tion are, in my judgment, complete rest in the horizontal posture, the 
limbs being secured in straight splints, constructed somewhat after 
the principle of Gibson's improvement of Hagedorn's apparatus; that 
is, the sound limb being first secured to the foot-board, and the broken 
limb subsequently brought down to the same point. In this way we 
may dispense with the perineal band as a means of counter-extension, 
which is so painful, indeed insupportable often, when the fracture is 



380 



FRACTURES OF THE FEMUR. 



at the neck, the hip of the broken limb being prevented from descend- 
ing by the lateral pressure of the two long splints. This apparatus 

Fig. 118. 





ililiilllliilill . ^ - 



Gibson's modification of Hagedorn's splint. 



possesses also this advantage, namely, that it presses the broken frag- 
ments more firmly against each other, and thus operates to prevent 
their displacement in the direction of the axis of the shaft. 



Fig. 119. 




Gibson's splint applied. 

In treating this fracture, supposing no displacement to exist, no 
extension beyond that which is necessary to insure perfect quiet can 
be proper, inasmuch as the fragments are not overlapped ; and they 
need only a moderate assistance to enable them to maintain their posi- 
tion against the action of the muscles. Moreover, if the fragments are 
impacted, violent extension ivould disengage them, and render their 
displacement and non-union inevitable. 

Of course, no side splints are necessary, but both limbs should be 
secured through their whole length to the long lateral splints, and 
properly supported by junks and pads. 

I am prepared to affirm, from my own experience, that more pa- 
tients will endure quietly this position for a length of time than the 
flexed position, whether in this latter the patient is placed upon his 
side or upon his back. 

How long the patient will submit to this, or to any other mode of 
securing perfect rest, is very uncertain, and the decision of this ques- 
tion must rest with the individual cases and the good sense of the 
surgeon. Not very many old and feeble people will bear such con- 
finement many days without presenting such palpable signs of failure 
as to demand their complete abandonment. 

A mode of treatment similar to this was adopted in Jones' case, and 
also in the case reported by Fawdington, and is said to have been 
successful. In Brulatour's case, the limb was kept extended two 



NECK, WITHIN THE CAPSULE. 381 

months ; In Mussey's second case Hartshorne's straight splint for ex- 
tension remained npon the limb eighty-four days ; in Bryant's case a 
long splint was used "some weeks." 

It is true, however, that other plans of treatment seem to have been 
equally successful. In the case reported by Adams the limb was 
placed over a double inclined plane, made of pillows, five weeks ; and 
in Mussey's third example the limb remained in the same position 
three months. Chorley laid his patient upon the sound side, with the 
thighs flexed, for a space of two weeks, and then turned him upon his 
back, still keeping the thighs flexed. At the end of six weeks he 
was placed in a straight position, &c. 

But in a majority of the examples reported, the existence of the 
fracture was either not suspected, or bony union was not anticipated 
or desired, consequently no treatment having in view the confinement 
of the broken bone was adopted. Yet, the success was as great as 
that which has followed from either of the other plans. Harris' 
patient was simply laid on a sofa. Field's patient, who broke the 
neck of both femurs within the capsule at different times, was in each 
case left without treatment, except that she laid upon her bed. Mus- 
sey himself removed all dressings from Dr. Dalton's patient on the 
eighteenth day, and placed him upon his feet, and Dr. Wakelee re- 
moved the apparatus from his mother on the fifth day. 

Nor are we without evidence that the careful and judicious applica- 
tion of splints, long continued, and employed under the most favor- 
able circumstances, will sometimes fail. The two following cases 
confirm these remarks. The first occurred in the practice of Dr. 
James R. Wood, of this city: "M. J., a young lady, set. 16 years; of 
vigorous constitution ; perfectly free from any constitutional taint, 
either of scrofula, syphilis, or cancer, was caught between the wheels 
of two carriages, the one stationary, the other in motion. The blow 
was received directly on the trochanter major of the right side. The 
symptoms which presented themselves showed conclusively that there 
was a fracture. There was shortening, loss of voluntary motion, and 
e version ; by placing the finger on the trochanter major, and the 
thumb in the groin, a well-marked crepitus could be felt on extension 
and rotation being made. There was no laceration or other compli- 
cation of the injury. She was placed on Amesbury's splint, with side 
splints accurately adjusted, and every precaution taken to insure a 
perfect union. The limb was kept on this splint without being dis- 
turbed for six weeks. At the end of that time it was taken from the 
splint, and examined with care. The signs' of fracture still remained; 
the limb was replaced on the splint, and the dressings as before ; 
everything was attended to in the general management of the case 
which the doctor thought would be conducive to perfect union. The 
patient was kept for three weeks longer on the splint, which was then 
removed. It was found that there was no union. Patient lived for 
three years, and was so lame that she was always obliged to use a 
crutch in walking. At the expiration of three years she died of an 
acute disease. 

" On examination of the cervix femoris, it was found that there had 



382 FKACTUKES OF THE FEMUR. 

been a transverse fracture of the bone just at the junction of the head 
and neck. The head of the boue was still attached to the acetabulum 
by the ligamentum teres. The process of absorption had been going 
on, and the head of the bone had already been absorbed below the 
level of the acetabulum, and what remained was soft and spongy, 
easily broken with the handle of the scalpel. The neck of the bone 
was rounded off) and covered with a fibrous deposit. This was not a 
case of diastasis, as has been suggested by an eminent surgeon, who 
judged simply from the age of the patient. She was full sixteen when 
the accident happened, and over nineteen when she died." 

The second was in the person of a man, set. 25 years, who was at 
the time of the accident robust and in good health : " He was dancing 
at his sister's wedding; while cutting a pigeon wing, he struck the 
foot upon which he was resting from under him, and fell, striking 
directly upon the trochanter major. He was unable to rise ; a carriage 
was called, and he was taken directly to the New York Hospital. 
There he came under the charge of Dr. J. Kearney Rodgers. A frac- 
ture was immediately diagnosticated, and for a few days he was kept 
on the double inclined plane. The straight splint was then used, and 
the dressings kept up for six weeks ; at the end of that time they were 
taken o&) and the limb examined ; there was no union. The limb 
was continued in the straight splints for three weeks longer, and again 
examined ; there was still no union. The patient was again replaced 
in the straight splint for two weeks longer, but no union occurred. 
At the end of three months from his admission he was discharged ; he 
was in good health, but so lame that he was obliged to use two crutches 
in walking. After his discharge the patient became very intemperate ; 
and in the course of a few weeks he applied for admission to Bellevue 
Hospital. He was much debilitated, and had an exhausting diarrhoea. 
Shortly after his admission, an immense abscess formed over the joint, 
which discharged profusely. The man died shortly after from exhaus- 
tion, and the specimen came into Dr. Yan Buren's hands, the patient 
having been in his service. Dr. Yan Buren was aware of the patient's 
previous history, the treatment, etc., at the New York Hospital, and 
a careful examination was made. 

" The capsular ligament was destroyed entirely by the suppurative 
process; there was a formation of callus upon the trochanter major; 
the ligamentum teres was entirely absorbed ; the head of the bone was 
spongy, as if worm-eaten ; the direction of the fracture was oblique, 
commencing just at the articulating surface of the head and ending 
just within the capsule; the upper end of the shaft of the bone showed 
this same appearance that was marked in the head. These points are 
beautifully shown in the specimen at the present time. The opinion 
of Charles E. Isaacs, M. D., the able Demonstrator of Anatomy of the 
University Medical College, is, that this fracture was entirely within 
the capsule." 1 The bone may be seen in the museum of Prof. Wm. 
H. Yan Buren, of the University Medical College, New York. 

Such equal results from opposite plans, and unequal results from 

1 Johnson, op. cit., pp. 13-15. 



CAPSULE. 383 

similar plans of treatment, are not calculated to increase our faith in 
the testimony which most of the foregoing examples are supposed to 
furnish of the possibility of bony union. On the contrary, they can- 
not fail to suggest a doubt as to whether some of them, at least, were 
not inaccurately diagnosticated. 

But admitting that they were not, the testimony which they furnish 
in relation to treatment is too inconclusive to be made available for 
instruction, and we are still at liberty to adopt that which' seems most 
rational, without reference to the experience of others. 

The reasons why I would prefer Hagedorn's plan have already been 
stated in part, to which I will now add, that if an error should occur 
in the diagnosis — if it should prove finally to have been a fracture 
without the capsule — then this treatment would be correct, and no 
injury would come to the patient from the error in diagnosis; but if 
we adopt Sir Astley Cooper's suggestion, namely, to get the patient 
upon crutches as soon as possible, perhaps as soon as fourteen days, 
an error in diagnosis might be followed by the most disastrous con- 
sequences. 

(b.) Neck of the Femur without the Capsule. 

Causes. — Like fractures within the capsule, these also occur most 
frequently in advanced life; age may therefore be regarded as the 
grand predisposing cause. 

As to the immediate causes, we have already mentioned in the pre- 
ceding section that fractures without the capsule seem to be the result 
generally of falls or of blows received directly upon the trochanter ; 
occasionally, also, they are produced by falls upon the feet or upon 
the knees. 

Pathology. — These fractures may occur at anjr point external to the 
capsule, but generally the line of fracture is at the base, corresponding 
very nearly with the anterior and posterior inter-trochanteric crests. 
Almost invariably the acetabular penetrates the trochanteric fragment 
in such a manner as to split the latter into two or more pieces. The 
direction of the lesions in the outer fragments preserves also a remark- 
able uniformity ; the trochanter major being usually divided from near 
the centre of its summit, obliquely downwards and forwards towards 
its base, and the line of fracture terminating a little short of the tro- 
chanter minor, or penetrating beneath its base ; while one or two lines 
of fracture usually traverse the trochanter major horizontally. 

In an examination of more than twenty specimens, I have noticed 
but two or three exceptions to the general rules above stated. 

In Dr. Mutter's collection, specimen marked B 115 is not accompa- 
nied with either impaction or splitting of the trochanteric fragment ; 
but the neck having been broken close to the inter-trochanteric lines, 
has, apparently, slid down upon the shaft about one inch, at which 
point it is firmly united by bone. 

Dr. Weill has also a specimen of fracture at the same point, but with- 
out union of any kind, in which no traces remain of a fracture of the 



384 



FEACTUEES OF THE FEMUR. 



trochanters. The acetabular fragment has moved up and down upon 
the trochanteric until it has worn for itself a shallow socket three 
inches and a half long ; the approximated surfaces being smooth and 
polished like ivory. 



Fig. 120. 



Fig. 121. 



Fig. 122. 




Impacted extra-capsular fractures. (R. Smith, and Erichsen.) 

The trochanter major is usually turned backwards, the shaft of the 
femur being rotated in this direction, the same as is usually observed 
in other fractures of the neck of the femur. I have seen one exception 
to this general rule in a specimen belonging to Dr. Mutter (No. 29) ; 
the trochanter in this instance is turned forwards, so that the neck is 
shorter in front than behind. 

The upper fragments of the trochanter major, whenever the lines of 
fracture are transverse, are generally inclined inwards toward the neck, 
as if displaced in this direction by the force of the blow, or perhaps 
by the resistance offered by certain muscles and ligamentous bands 
which find an insertion upon its summit. 

The neck is found, in most cases, standing inwards at nearly a right 
angle with the shaft, the head being much more depressed than the 
outer extremity of the neck ; in consequence of which the lower margin 
of its broken extremity is driven much deeper into the trochanteric 
fragment than is the upper margin. 

Malgaigne believes that impaction with consequent fracture of the 
trochanters, is never absent in true extra-capsular fractures, unless it 
be in that very unusual variety in which the trochanter forms a part 
of the inner fragment (fractures through the trochanter major and 
base of the neck). Robert Smith entertains the same opinion, although 
Malgaigne does not seem to have so understood him. I cannot agree, 
however, with either of these gentlemen that the rule is so invariable, 
since I am confident that no such splitting has occurred in either of 
the two specimens to which I have referred as belonging respectively 



CAPSULE. 385 

to Drs. Mutter and Neill. It is true these are both old fractures, and 
to some extent the signs of fracture may have become obliterated, but 
in Mutter's specimen an abundant callus indicates plainly enough 
where the shaft separated from the neck, while the trochanter major 
is smooth as in its normal condition, nor does its summit incline either 
way from its usual position. Neill's specimen, though less satisfactory, 
does not fail to convince me that neither impaction nor splitting of the 
trochanters ever occurred. 

It is certain, however, that impaction and comminution of the outer 
fragment are very constant, and that, whether the fracture is produced 
by a fall upon the feet or upon the trochanter major. But the impac- 
tion does not necessarily continue ; sometimes, indeed, it does, and 
the position of the limb, whatever it may be at the moment, remains 
unalterably fixed ; either very little or considerably shortened, accord- 
ing to the degree of impaction; rotated outwards or inwards, or in 
neither direction, perhaps, according to the direction of the force 
and of the fracture. In other cases, owing to the extreme comminu- 
tion, and to the wide separation of the trochanteric fragments, or to 
the contraction of the muscles inserted into the top of the femur, or 
to the weight of the body in attempts to walk, or to injudicious hand- 
ling on the part of the surgeon, such as forcible rotation, by which 
the neck is made to act as a lever, and to actually pry the fragments 
apart, or to violent extension, by which the impaction is overcome — 
owing to some one or several of these causes it often happens that the 
fragments separate, and the leg becomes immediately more shortened, 
movable, and more inclined to rotate outwards. 

Symptoms. — The symptoms which indicate a fracture of the neck 
of the femur without the capsule, are pain, mobility, crepitus, short- 
ening and eversion of the limb. The trochanter major is not as pro- 
minent as upon the opposite side, and it rotates upon a shorter axis. 
There are also several other signs to which I shall refer when consi- 
dering the differential diagnosis. 

o o 

The pain and tenderness, accompanied sometimes with swelling and 
discoloration, are situated chiefly in front of the neck of the bone. 

Mobility exists in a majority of cases, even when the fragments are 
impacted ; that is, the limb can be moved pretty easily in any direc- 
tion by the surgeon, but not without producing pain or provoking 
muscular spasms, yet the patient himself is unable to move the limb 
by his own volition, or he can only move it slightly. 

Crepitus is present whenever there exists a moderate but not com- 
plete impaction. It is also present generally when, the trochanteric 
fragment having been extensively comminuted and loosened, the 
impaction becomes excessive: and it is only absent when the impac- 
tion is such that the fragments are completely and firmly locked into 
each other. 

A shortening is inevitable, at least in all cases accompanied with 
either temporary or permanent impaction, and we have seen that one 
of these conditions seldom fails. According to Sir Astley Cooper the 
shortening varies from half an inch to three-quarters of an inch, but 



386 



FRACTUKES OF THE FEMUR. 



Kobert Smith has established the following distinction. When the 
fracture is extra-capsular and impacted, that is, when it remains im- 
pacted, the shortening is only moderate, varying 
from one-quarter of an inch to one inch and a 
half; in fourteen cases measured by him the aver- 
age was a fraction over three-quarters of an inch ; 
but when it does not remain impacted it ranges 
from one inch to two inches and a half; indeed, 
Mr. Smith mentions one example in which the 
shortening reached four inches, and forty-two 
cases gave an average shortening of something 
more than one inch and a quarter. 

Eversion of the toes is very constant; but in a 
few instances upon record the toes have been 
found turned in, or even directed forwards. 
During the winters of 1864 and '65 I found a case 
of this kind in my wards at Bellevue Hospital. 
In the specimen referred to as being found in Dr. 
Mutter's collection, with an inward or forward 
rotation of the trochanter major, the same relative 
position of the whole limb must have existed. 

The trochanter major usually seems depressed 
or driven in, and, when the two main fragments 
are completely separated, if the limb is rotated, 
the trochanter will be found to turn almost upon 
its own axis, or upon a very short radius. 
In enumerating the signs of extra-capsular fracture, it will be seen 
that I have, with only slight variations, repeated the signs of a fracture 
within the capsule. It will become necessary, therefore, to indicate, 
as far as possible, a differential diagnosis. And without pretending 
that all of the differential signs which I shall enumerate are thoroughly 
established, or that in every case, even after a careful grouping of all 
the symptoms, a satisfactory diagnosis can be made out, I shall state 
briefly my own conclusions, or, rather what seem to me to be the 
probable facts. 




Fracture of the neck of the 
Femur. (Fergusson.) 



trip 



Signs of a fracture within the capsule. I Signs of a fracture without the capsule. 

Produced by greater violence. 
A fall upon the trochanter major. 

Often under fifty years of age. 

Relative frequency in males or females 
not established. 

Pain, swelling, and tenderness greater 
and more superficial. It is especially pain- 
ful to press upon and around the trochan- 
ter. 



Produced by slight violence. 
A fall upon the foot or knee, or 
upon the carpet, &c. 

Generally over fifty years of age. 
More frequent in females. 



Pain, tenderness, and swelling less and 
deeper. 



(The two following measurements to be 
made from the anterior superior spinous 
process of the ilium to the lower extremity 
of the malleolus externus or interims.) 

Shortening at first less than in extra- 
capsular fractures, often not any. 



Shortening at first greater, almost always 
some. 



CAPSULE. 



387 



Skins of a fracture within the capsule. 

Shortening after a few days or weeks 
greater than in extra-capsular fractures. 
Sometimes this takes place suddenly, as 
when the limb is moved, or the patient 
steps upon it. 

Measuring from the top of the trochanter 
to the inner condyle or to the malleolus 
internus, the femur is not shortened. 

More mobility of limb, at joint. 

Trochanter major moves upon a longer 
radius. 

If the patient recovers the use of the 
limb, not restored under three or four 
months. 

No enlargement or apparent expansion 
of the trochanter major, after recovery, 
from deposit of bony callus. 

Progressive wasting of the limb for many 
months after recovery. 

Excessive halting, accompanied with 
a peculiar motion of the pelvis, such as is 
exhibited in persons who walk with an 
artificial limb. 



Signs of a fracture without the capsule. 

Shortening after a few days or weeks 
less than in intra-capsular fractures. That 
is, the amount of shortening changes but 
little, if at all ; if the impaction continues, 
not at all ; if it does not continue, it may 
shorten more. 

Measuring from the top of the trochanter 
to the inner condyle or to the malleolus 
internus, the femur may be found a little 
shortened. 

Less mobility. 

Trochanter major moves upon a shorter 
radius. 

If the patient recovers the use of the 
limb, restored in six or eight weeks. 

Enlargement or irregular expansion of 
trochanter, which may be felt sometimes 
distinctly through the skin and muscles. 

The limb preserving its natural strength 
and size. 

Slight halt, motions of hip natural. 



Fig. 124. 



Prognosis. — In attempting to establish the differential diagnosis, we 
have necessarily been led to consider most of the essential points of 
prognosis. Yery little, therefore, remains to be 
said upon this subject. 

Union generally occurs as rapidly in this frac- 
ture as in fractures of the shaft, and perhaps 
even sometimes more promptly, owing to the 
existence of impaction. 

. But whether it occurs promptly or slowly, or, 
indeed, if it does not occur at all, a remarkable 
deposit of ossific matter almost invariably takes 
place along the inter- trochanteric lines, where 
the bone has separated from the shaft, and also, 
not unfrequently, along the lines of the other 
fractures of the trochanter. 

This deposit is no less remarkable for its abund- 
ance than for its irregularity, long spines of bone 
often rising up toward the pelvis and forming a 
kind of knobby or spiculated crown, within 
which the acetabular fragment reposes. In a 
few instances these osteophites have reached 
even to the bones of the pelvis, and formed powerful abutments which 
seemed to prevent any farther displacement of the limb in this direc- 
tion, and, by some writers, they have been supposed thus to fulfil a 
positive design. A sufficient explanation of their existence, however, 
we think, can be found in the fact that they proceed entirely from the 
trochanteric fragments, Avhose extensive comminution and great vascu- 
larity would naturally lead to such results. The same, but in a less 




Extra-capsular fracture. 
(Erichsen.) 



388 



FRACTURES OF THE FEMUR. 



degree, has already been noticed as occurring in impacted fractures at 
the anatomical neck of the humerus, where certainly such bony abut- 
ments could not serve any useful purpose. 



Fig. 125. 



Fig. 126. 





Extra-capsular fractures. (E. Smith.) 



Fig. 127. 



Treatment. — The same principles of treatment are applicable here 
as in fractures of the neck within the capsule ; by which I mean to 
say that, as in all of those examples of fracture within the capsule 
where the relation of the fragments is such as to warrant a hope that 

a bony union may be consummated, 
namely, where the fragments are not dis- 
placed or are impacted, the straight splint, 
with only moderate extension, constitutes 
the most rational mode of treatment; so 
also in this fracture, whenever the frag- 
ments are impacted and remain impacted, 
a straight splint, employed only as a re- 
tentive apparatus, is the most suitable. 
It is only by employing this plan of treat • 
ment, which no one has yet shown to be 
inapplicable to either of these two varie- 
ties of accidents — I do not speak of the 
opinions which men may have entertained, 
but of the practical testimony — it is only, 
I say, by employing this uniform plan of 
treatment in both cases, that those serious 
misfortunes to the patient can be avoided which would necessarily 
continue to occur if Sir Astley Cooper's advice was followed, namely, 
to allow the patient in the one case to dispense with splints wholly, 
and to get upon his crutches as soon as the condition of his limb and 
of his body will permit, when it is certain that in the other case some 




Extra-capsular fracture. 



NECK, WITHOUT THE CAPSULE 



389 



retentive apparatus is generally necessary. This conclusion is based 
upon the admitted difficulty of diagnosis. If, as is well understood, 
the diagnosis between these two varieties of fracture can seldom be 
made out satisfactorily during the life of the patient, then how shall 
we know in any given case which of the two plans to adopt. If we 
act upon the supposition that it is within the capsule, adopting Sir 
Astley Cooper's method, and it proves to have been a fracture without 
the capsule, we have, I fear, done irreparable injury to our patient. 
It is precisely here that this distinguished surgeon committed his great 
error : not in denying that certain specimens were fractures of the neck 
of the femur within the capsule united by bone, nor in constantly urg- 
ing upon his contemporaries the improbability of such an event ; but 
in that, while he admitted its possibility, he chose to recommend a plan 
of treatment which was unlikely to insure such a union, and which, 
in the uncertainty if not impossibility of diagnosis, was liable, upon 
his supposed authority, to be adopted in many cases of extra-capsular 
fractures. 

Again, if the fracture be extra-capsular and not impacted, or the 
impaction has been, for any cause, overcome ; or, if the fracture be 
intra-capsular and not impacted, or if the capsule is lacerated and the 
fragments are in consequence displaced ; then again no injury need 
result from the treatment, if we adopt the straight splint with mode- 
rate extension, such as may be obtained from the use of Hagedorn's 
splint modified by Gibson, or by the use of Miller's splint, or Buck's 
apparatus with only six or eight pounds of extension. That it is not 
impacted we may know often, or generally, by the amount of displace- 
ment, although we may not easily decide whether the fracture is 
within or without the capsule. ISTow the amount of shortening will 
determine, properly enough, the amount of extension to be employed. 
In either case we shall not employ, because the patient will not per- 
mit, as much extension as in fractures of the shaft ; and while in the 
one case we shall only gain a shorter and firmer ligamentous union, 
in the other we shall insure a better and more speedy bony union. 

If any surgeon, acting upon the suggestions here made, shall con- 
fine a feeble or an aged person in the horizontal posture, and in a 

Fig. 12^. 




Miller's splint for extra-capsular fractures. (From Miller.) 



straight splint until the powers of nature have become exhausted, and 
death ensues, as our readers have already been admonished may 



390 FRACTURES OF THE FEMUR. 

happen, we are not to be held responsible for his want of judgment or 
of skill. We have advised this plan of treatment only for so long a 
period as the condition of the patient renders it entirely safe. No 
doubt, then, in a large number of cases it will have to be abandoned 
very early, and in not an inconsiderable proportion all constraint will 
be plainly inadmissible from the beginning; and it is for such ex- 
amples that the treatment recommended by Sir Astley Cooper for all 
intra-capsular fractures ought to be reserved. 

(c.) Fractures of the Neck partly within and partly without the Capsule. 

It is scarcely necessary to say that the line of fracture through the 
neck of the femur may be such, that it shall be in part within and in 
part without the capsule ; and such fractures will be even more diffi- 
cult to diagnosticate than either of those forms of which we have just 
spoken. The symptoms will be mainly, however, those which cha- 
racterize fractures within the capsule, while the treatment ought to be 
such as we would adopt in those fractures which are wholly without 
the capsule. The chances for bony union are increased in proportion 
as the line of separation extends outside of the capsule, and we ought 
to be diligent in our efforts, if we have made ourselves certain that 
the fracture is partly extra-capsular, to secure a good bony union ; a 
result which experience has shown may be reasonably anticipated. 

The necessity for some extension, and of a firm retentive apparatus 
in this form of fracture, furnishes another argument in favor of the 
employment of the same means in fractures wholly within the capsule. 
We shall thus avoid the mischief which might arise from mistaking a 
fracture of the character of which we are now speaking, for a fracture 
wholly within the capsule. 



§ 2. Fracture through the Trochanter Major and Base of the 
Neck of the Femur. 

This fracture, which Sir Astley Cooper calls a " fracture of the femur 
through the trochanter major," 1 passes obliquely upwards and outwards 
from the lower portion of the neck, but instead of traversing the neck 
completely, it penetrates the base of the trochanter major ; the line of 
fracture being such as to separate the femur into two fragments, one 
of which is composed of the head, neck, and trochanter major, and the 
other of the shaft with the remaining portions of the femur. 

The following two examples are all in relation to which we possess 
any positive information, or in which the diagnosis has been con- 
firmed by an autopsy. The first is thus related by Sir Astley Cooper. 

" The first case of this kind I ever saw was in St. Thomas's Hos- 
pital, about the year 1786. It was supposed to be a fracture of the 
neck of the thigh-bone within the capsule, and the limb was extended 
over a pillow rolled under the knee, with splints on each side of the 

1 Sir Astley Cooper, op. cit., p. 183. 



BASE OF THE TROCHANTER- MAJOR. 391 

limb, by Mr. Cline's direction. An ossific union succeeded, with 
scarcely any deformity, excepting that the foot was somewhat everted, 
and the man walked extremely well. When he was to be discharged 
from the hospital, a fever attacked him, of which he died ; and upon 
dissection, the fracture was found through the trochanter major, and 
the bone was united with very little deformity, so that his limb would 
have been equally useful as before." 1 

The second example is reported by Mr. Stanley. 

" A woman, in her sixtieth year, fell in the street and injured her 
right hip. On examination, the limb was found slightly everted, and 
shortened to the extent of three-quarters of an inch, but movable in 
every direction. The extremity of the shaft of the femur was in its 
natural situation ; but behind the femur, and at a little distance from 
it, a bony prominence was discovered, resting upon the ilium, toward 
the great sciatic notch, strongly resembling the head of the femur. 
Yarious opinions were entertained as to the nature of the injury, some 
believing it to be dislocation, and others a fracture. After a confine- 
ment of several months to her bed, the woman was sufficiently re- 
covered to walk with the assistance of a crutch, and in this state she 
continued till her death, which took place about three years after the 
accident, during the whole of which period I had watched the pro- 
gress of the case. Having obtained permission to examine the seat of 
the injury, I ascertained that there had been a fracture extending 
obliquely through the trochanter major, and through the basis of the 
neck into the shaft of the femur, and that the prominence which had 
been mistaken for the head of the bone was occasioned by the posterior 
and larger portion of the trochanter drawn backwards toward the 
ischiatic notch."- 2 

Sir Astley relates three other examples in which he believes the 
fractures to have been of the character above described ; and he details 
the peculiar plans of treatment which, in each case, he saw fit to recom- 
mend. I can see no reason, however, why the treatment need differ 
from that which has already been reeommended for fractures of the 
neck, since the indications are nearly identical in all of these cases ; 
namely, moderate extension, and steady support of the limb in its 
natural position. 

§ 3. Fracture of the Epiphysis of the Trochanter Major. 

So far as I know, the only well-authenticated example of this acci- 
dent is the one reported by Mr. Key to Sir Astley Cooper. 3 The sub- 
ject of this case was a girl, aged about sixteen years, who fell, March 
15, 1822, upon the side-walk, and struck her trochanter violently 
against the curb-stone. She arose, and, without much pain or difficulty, 
walked home. On the 20th she was received into Gruy's Hospital, and 
the limb was examined by Mr. Key. The right leg, which was the 

1 Op. cit. , p. 184. 2 Stanley, Med.-Chir. Trans., vol. xiii. 

3 Sir Astley Cooper on Dislocations and Fractures, etc., Atner. ed., 1851, p. 192. 



392 FRACTURES OF THE FEMUR. 

one injured, was considerably everted, and appeared to be about half 
an inch longer than the sound limb. It could be moved in all 
directions, but abduction gave her considerable pain. She had perfect 
command over all the muscles, except the rotators inwards. No 
crepitus could be detected. Four days after admission she died, having 
succumbed to the irritative fever which followed the injury. 

The autopsy disclosed a fracture through the base of the trochanter 
major, but without laceration of the tendinous expansions which cover 
the outside of this process, so that no displacement of the epiphysis 
had occurred, nor could it be moved, except to a small extent upwards 
and downwards. A considerable collection of pus was found, also, 
below and in front of the trochanter. 

The absence of displacement in the fragment, with its peculiar and 
limited motion, sufficiently explained why the fracture could not be 
detected during life. 

In the eighth volume of the Transactions of the Medical and Physical 
Society of Calcutta (1835), J. Clarke, Esq., reports a case of comminuted 
fracture of the trochanter major, which has been mentioned by Mal- 
gaigne as an example of simple fracture of the trochanter ; but, after 
reading the case carefully, I cannot avoid the conclusion that it was 
an example of fracture of the neck without the capsule, accompanied 
with impaction and extensive comminution. " Extravasation," says 
Mr. Clarke, " was discovered within the capsular ligament and around 
the trochanter major ; and, on clearing away the muscles, the trochan- 
ter was found crushed and shattered, several pieces entirely detached, 
and fissures extending deeply into the shaft of the bone." 1 

I shall venture to express the same opinion in relation to the case 
reported by Bransby Cooper. 2 The diagnosis was not confirmed by 
an autopsy, and the testimony drawn from Mr. Cooper's account of 
the case is far from being, to my mind, conclusive. It may, indeed, 
have been a simple fracture of the epiphysis ; but there is nothing in 
the narrative to render it improbable that there existed also an im- 
pacted extra-capsular fracture of the neck. 

I have also myself reported one example of this fracture as having 
come under my own observation, 3 but of which I wish now to speak 
somewhat less confidently. The patient, James Eedwick, a travelling 
showman, set. 23, fell, in August, 1848, from a high wagon, striking 
upon his left hip. When he got upon his feet, he found himself un- 
able to walk, and was carried to his room. Dr. Wilcox, of Buffalo, 
was called to see him, and applied a long straight splint. Fourteen 
days after the accident I saw the patient with Dr. Wilcox. The thigh 
was not appreciably shortened, nor was there either eversion or inver- 
sion; but the epiphysis of the trochanter major was carried upwards 
toward the crest of the ilium half an inch, and slightly sent in. No 
crepitus could be detected. The splint was continued five weeks ; and 
about a month after, I found the fragment in the same place, but he 
was able to walk with only a slight halt. 

1 Clarke, Amer. Journ. Med. Sci., Nov. 1836, vol. ix. p. 181. 

2 B. Cooper, A. Cooper on Dislocations, &c, op. cit., p. 192. 

3 Hamilton, Trans. Amer. Med. Assoc, op. cit., vol. x. p. 254. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



393 



I think this also may have been an extra-capsular impacted fracture. 

With the small amount of positive information which we possess in 
relation to this fracture, we might venture a few conjectures as to what 
would constitute its symptoms, or as to the probable results and the 

Fig. 129. 




Sir Astley Cooper's mode of treating fractures of the trochanter major. (From A. Cooper.) 

most suitable treatment ; but we prefer to occupy ourselves with a 
simple statement of the facts, so far as they are known, leaving all 
mere speculative inferences to those who choose to make them. 



§ 4. Fractures op the Shaft of the Femur. 

Etiology. — Unless the fracture has taken place just above the con- 
dyles, or immediately below the trochanter minor, in a very large 
proportion of cases it has been produced by a direct blow, such as 
the passage of a loaded vehicle across the thigh, or the fall of a piece 
of timber directly upon it. An analysis of twenty-one cases, taken 
indiscriminately, presents three fractures immediately above the con- 
dyles, and these were all produced by falls upon the feet ; but of the 
remaining eighteen, all of which occurred higher in the limb, only 
two were the result of falls upon the feet or of indirect blows, and 
one of these was a fracture just below the trochanter minor. 

Pathology. — It has already been remarked that this bone is most 
frequently broken in its middle third, and usually at a point some- 
what above the middle of the shaft. I have made the same observa- 
tion in an examination of specimens belonging to Dr. Mutter. In 
his cabinet, of twenty-four fractures of the shaft, three belonged to the 
upper third, two to the lower, and nineteen to the middle third. 

In the adult, these fractures are, with only an exceedingly rare ex- 
ception, oblique ; and the obliquity is generally greater than in the 
case of other bones. This fact, which it is very difficult to deter- 
mine, in most cases, upon the living subject, I have established by a 
considerable number of observations made upon cabinet specimens. 
A transverse fracture is found only twice in Dr. Mussey's collection, 
containing thirty examples of fracture of the shaft ; and in Dr. Mut- 
ter's collection, specimen B 71 is an adult femur, broken nearly trans- 
versely through its middle third ; and it is united with a shortening 
of about one inch. Indeed, it is more common to find a transverse 
26 



394 



FRACTURES OF THE FEMUR, 



fracture in the middle third than at any other point of the bone ; but 
in the upper third the obliquity is extreme and almost constant. 

At whatever point of the shaft the bone is broken, the degree of 
obliquity is generally such that the fragments cannot support each 
other when placed in apposition ; unless indeed the fracture is near 
the condyles, where the greater breadth of the bone creates an addi- 
tional support ; but even here the cabinet specimens still present a 
striking obliquity with more or less overlapping. I believe that in 
each of the three specimens of fracture at this point found in the 
collection belonging to the Albany Medical College, the obliquity is 
such that the fragments were not supported, and an overlapping has 
taken place. In specimen 719 the fracture extends into the joint; 
and although it is united by bone, a shortening of about one inch has 
occurred. 

In the case of children, and especially of infants, the rule is reversed ; 
the bone is either broken transversely or nearly transversely, or it is 
serrated or denticulated, so that complete lateral displacement is much 
less frequent. 

The same remark is probably true of some fractures occurring in 
extreme old age; but as the shaft of the femur is not often broken in 
very old persons, owing to the readiness with which the neck yields 
to violence, I have not had an opportunity to verify this opinion. 

The direction of the obliquity varies exceedingly, especially in the 
middle and upper thirds ; in the middle third, however, it is generally 
downwards and inwards; but in the lower 
Fig. 130. third its direction is, with only rare excep- 

tions, downwards and forwards, and the su- 
perior fragment is found lying in front of 
the inferior. 

In one instance I have found both femurs 
broken at the same point and in the same 
manner. Mr. L. Brittin, aged about fifty -five 
years, while employed upon a building, fell 
from a fourth story window upon the stone 
pavement below, striking upon his feet. In 
addition to several other fractures, I found 
both femurs broken obliquely downwards 
and for wards, just above the condyles. Yery 
little inflammation ensued, and although it 
was found impossible to employ extension, 
union occurred readily, and with only a mode- 
rate overlapping. In the left limb, however, 
the upper fragment pressed down sufficiently 
to interfere somewhat with the patella, and 
the patient was unable, after several months, to straighten the knee 
completely. The motions of the right knee were unimpaired. 

I have only once met with a fracture at this point in which the line 
of separation was downwards and backwards. As the case presents 
several points of interest, it will be proper to narrate the facts some- 
what at length. 




Fracture at base of condyles. 



FRACTUEES OF THE SHAFT OF THE FEMUR. 395 

George Taylor Aiken, of Lockport, 1ST. Y., set. 7. ■ May 18, 1854, in 
jumping down a bank of about three feet in height, he broke the right 
thigh obliquely, just above the knee-joint. Direction of the fracture 
obliquely downwards and backwards. 

Dr. G., an accomplished surgeon, residing in Lockport, was called. 
The limb was not then much swollen. He applied side splints, rollers, 
&c, carefully, and then laid the limb over a double-inclined plane. 
The knee was elevated about six or eight inches. Before applying 
the splints, suitable extension had been made, and after completing 
the dressings, the two limbs seemed to be of the same length. 

On the second or third day, Dr. Gr. noticed that the toes looked un- 
naturally white, and were cold. 

Counsel was now called at the request of Dr. G., when it was de- 
termined to abandon all dressings, and direct their efforts solely to 
saving the limb. 

The result was that slowly a considerable portion of his foot died, 
and sloughed away, leaving only the tarsal bones. The fracture 
united, but with considerable overlapping and deformity. 

Feb. 26, 1856, the boy was brought to me by his father. On ex- 
amining the fracture I noticed that the anterior line of the femur 
seemed nearly straight, and this appearance was owing in some de- 
gree to the muscles which covered and concealed the bone, and in 
some degree, also, to the manner in which the fragments rested upon 
each other : the pointed superior end of the lower fragment resting 
snugly upon the front of the upper fragment, so that no abrupt angle 
existed in front. On the back of the limb, however, the lower end 
of the upper fragment, quite sharp, projected freely downwards and 
backwards into the popliteal space, so that its extreme point was 
only about half an inch above the line of the articulation. The limb 
had shortened one inch, and this enabled us to determine accurately 
that the lower point or the commencement of the fracture was one 
inch and a half above the articulation, while the point where the line 
of fracture terminated in front was probably quite three inches and a 
half above the joint. 

The motions of the knee-joint were pretty free. The leg was ex- 
tremely wasted, and the anterior half of the foot having sloughed off, 
the sores had now completely healed over. He was able to walk 
tolerably well without either crutch or cane. 

Subsequently, Dr. Gr. found it necessary to sue the father of the 
child for the amount of his services, when Mr. Aikin put in a plea of 
malpractice, and that consequently the services were without value. 

The case was tried in the March term of the Niagara circuit of 
1856, at Lockport, N. Y., the Hon. Benj. F. Greene presiding. 

On the part of the defence, it was claimed that the death of the foot 
was in consequence of the bandages being too tight. They failed, 
however, to show that they were extraordinarily or unduly tight. 
While on the part of Dr. G., the prosecutor, it was shown that the 
death of the toes was preceded by a total loss of color, and that it was 
not accompanied with either venous or arterial congestion. The medi- 
cal gentlemen examined as witnesses declared that this circumstance 



396 FRACTURES OF THE FEMUR. 

furnished the most positive evidence which could be desired that the 
death of the toes was not due to the tightness of the bandages, but that 
its causa must be looked for in an arrest of the arterial or nervous 
currents supplying the limb, or in both. They believed, also, that 
the projection of the superior fragment into the popliteal space was 
sufficient to cause this arrest. They also believed that overlapping 
and consequent projection could not have been prevented in this case, 
and that, therefore, the treatment was not responsible for this unfor- 
tunate result : indeed, they regarded the treatment as correct, and the 
result as a triumph of skill, in that any portion of the limb was saved ; 
the leg and foot now remaining being far more useful than any artifi- 
cial leg and foot could be. 

The Hon. Judge, in a speech remarkable for its clearness and libe- 
rality, sought to impress upon the jury the value of the medical testi- 
mony. The jury returned a verdict for Dr. GL, allowing the amount 
of his claim for services, with the costs of suit. 

Specimen 121, in Dr. March's collection at Albany, presents a 
similar disposition of the fragments. The fracture is oblique, from 
above downwards and backwards, and the upper portion lies behind 
the lower. It is firmly united by bone, but with an overlapping of 
from two and a half to three inches. The young gentleman who 
showed me the specimen remarked that it had been found impossible, 
owing to an ulcer upon the heel, and to other causes, to employ in the 
treatment any degree of extension. 

These two are the only examples which have come under my ob- 
servation in which a fracture at this point has taken this direction. 

Sir Astley Cooper does not seem to have recognized this form of 
fracture and displacement. Amesbury has, however, recorded one 
case, which came under his own observation, where, although the 
bloodvessels and nerves escaped, the bone projected through the skin 
in the ham, and finally exfoliated. 1 And he thinks the point of bone 
may sometimes so penetrate the artery and injure the nerves as to 
render amputation necessary, in order to save the life of the patient. 

M. Coural also has related a case in which an epiphysary disjunc- 
tion, occurring in a child twelve years old, was attended with a dis- 
placement of the upper fragment backwards, and amputation became 
necessary. 2 I shall refer to this case again. 

I know of no other cases of this rare accident which have been re- 
ported. Lonsdale refers to it as " the rarest direction for a fracture to 
take;" and thinks that in case of its occurrence, the vessels in the popli- 
teal space will stand a chance of being wounded ; but he mentions no 
example. The popliteal artery hugs the bone so closely at this point, 
that a displacement of the upper fragment in a direction downwards 
and backwards must always greatly endanger its integrity. Indeed, 
it is here that the artery and vein are in the closest contact with each 
other, and with the bone ; an anatomical fact which has been used by 
Eicherand and others to explain the greater frequency of aneurisms 
in the ham. 

1 Remarks on Fractures, &c, by Joseph Amesbury, vol. i. p. 293. London, 1831. 

2 Arckiv. Gen. de Med., torn. ix. p. 267. 



FRACTURES OF THE SHAFT OF THE FEMUR. 397 

The direction of the displacement, however, in fractures of the shaft 
of the femur, does not always depend upon the direction of the line of 
fracture. In fractures of the upper third, whatever may be the direc- 
tion of the line of fracture, the lower end of the upper fragment 
inclines forwards and outwards, and the upper end of the lower frag- 
ment inwards ; unless, indeed, this inclination is controlled by actual 
entanglement of the broken ends with each other. 

In the middle third the fragments also generally take the same 
relative position, whatever may be the direction of the fracture; but 
when the fracture takes place at or near the condyles, where the 
diameter of the bone is much greater, the direction of the obliquity 
determines pretty uniformly the direction of the displacement. 

Symptoms. — The symptoms which characterize a fracture of the 
shaft of the femur are those which are common to all fractures, 
namely, mobility, crepitus, displacement of the fragments, pain, and 
swelling, to which are added generally a shortening of the limb, with 
eversion of the foot and leg. 

Owing to the great amount of muscle covering the thigh, and some- 
times to the swelling which immediately follows the injury, it is often 
very difficult to determine at what precise point the fracture has oc- 
curred, and still more difficult to say whether the fracture is oblique 
or transverse ; indeed, this latter question is sometimes decided ap- 
proximately by a reference to the age of the patient rather than by 
the examination of the limb. 

The immediate shortening varies from half an inch to an inch and 
a half, or even more ; and it will average about one inch in the case 
of healthy adults. 

Prognosis. — Whatever may have been the general opinion of ex- 
perienced surgeons as to the question of shortening in other fractures, 
very few certainly have ever claimed that in fractures of the femur a 
complete restoration of the bone to its original length was generally 
to be expected. There seem, however, to have existed only certain 
vague and indefinite notions as to the proportion and amount of this 
shortening, and which have had for their basis nothing better than a 
few imperfectly analyzed observations. 

Says Scultetus (quoting first from Hippocrates) : "'For the bones of 
the thigh, though you do draw them out by force of extension, cannot 
be held so by any hands ; but when the first intention slacks, they will 
run together again; for here the thick and strong flesh are above 
binding, and binding cannot keep them down.' — Hippocrates de fract. 
"Which Celsus seems to confirm, Lib. 8, cap. 10, where he writes as 
follows of the cure of legs and thighs : ' For we must not be ignorant 
that if the thigh be broken, that it will be made shorter, because it 
never returns to its former state.' And Avicenna, Lib. 4, Fen. 5, saith 
' that is is a rare thing for the thigh once broken, to be perfectly cured 
again.' 

" These words admonish us," continues Scultetus, " that we should 
never promise a perfect cure of the thigh; but rather, using all 
diligence, we should foretell that it is doubtful that the patient will be 
always lame ; but when this shall happen from the nature of the frac- 



398 FRACTURES OF THE FEMUR. 

ture, or which most frequently falls out, from the impatience of the 
sick person, it may be imputed to our mistake ; and, instead of a 
reward, bring us disgrace." 1 

Says Chelius : " Fracture of the thigh-bone is always a severe acci- 
dent, as the broken ends are retained in proper contact with great 
difficulty. The cure takes place most commonly with deformity and 
shortening of the limb, especially in oblique fractures, and those which 
occur in the upper and lower third of the thigh-bone. Compound 
fractures are so much more difficult to treat." 2 

Says John Bell: "The machine is not yet invented by which a 
fractured thigh-bone can be perfectly secured." And Benjamin Bell 
declares that " an effectual method of securing oblique fractures in the 
bones of the extremities, and especially of the thigh-bone, is perhaps 
one of the greatest desiderata in modern surgery." In all ages," he 
adds, "the difficulty of this has been confessedly great ; and frequent 
lameness produced by shortened limbs arising from this cause, evi- 
dently shows that we are still deficient in this branch of practice." 3 

Yelpeau says that " after fractures of the femur there is no limp- 
ing unless the shortening exceeds three-quarters of an inch ; and the 
same is true if the shortening occurs in the tibia." The reason is, that 
the pelvis inclines toward the shorter limb, and thus compensates for 
the deficiency in length. In speaking of the various contrivances for 
dressing the fractured femur, he remarks that " most of them fail to ob- 
viate the shortening, and produce eschars, anchylosis, or troublesome 
arrests of the circulation. This is the price that is usually paid for 
the employment of these complicated machines, and a shortening of a 
quarter to three-quarters of an inch is not avoided after all. The 
simplest apparatus that will maintain the adjustment of the fractured 
femur, so that union may take place with shortening of only half an 
inch, is the best." 4 

Nelaton holds the following language : — 

" A fracture of the body of the femur, with an adult, is always a 
grave accident, inasmuch as it demands so long a confinement to the 
bed, and especially on account of the shortening of the limb, which it 
is almost impossible wholly to prevent; accordingly, Boyer recommends 
to the surgeon, from the first day, to announce to the parents of the 
patient the possibility of this accident. With infants, on the contrary, 
it is almost always easy to avoid the shortening." 5 

While Malgaigne declares his opinion on this subject thus, at 
length : — 

" When we do not succeed in drawing back the misplaced fragments, 
end to end, so that they may oppose themselves to the action of the 

1 The Chirurgeon's Store-house, by Johannes Scultetus, a Famous Physician, and 
Chirurgeon of Ulme in Suevia. London, 1674. 

2 System of Surgery, by J. M. Chelius, translated, &c, by South. First Amer. ed., 
vol. i. p. 627, 1847. See also p. 625, paragraph 679. 

3 System of Surgery, by Benjamin Bell, vol. vii. p. 21. Edinburgh, 1801. 

4 Peninsular Journ. of Med., vol. iii. p. 384; also Memphis Med. Journ., vol. iv. 
p. 254, 1856. 

5 Elemens de Pathologie Chirurgicale, par A. Nelaton, torn, prem., p. 752. Paris, 
1844. 



FKACTURES OF THE SHAFT OF THE FEMUR. 399 

muscles, it is impossible to preserve to the member its normal length, 
whatever may be the appareil or method employed. Surgeons are 
not sufficiently agreed upon this question. 

" Hippocrates gives us to understand that we can always correct 
the shortening; Celsus, falling into the opposite error, declared that 
a broken thigh always remains shorter than the other. At a period 
quite recent, Desault pretended to cure all fractures without shortening, 
and his journal contains several examples. In imitation of Desault, 
various practitioners have modified, corrected, and improved the ap- 
paratus for permanent extension, and they claim to have themselves 
obtained as complete success. I ought then to declare here in the 
most positive manner that I have never obtained like results, either 
in the use of my own apparatus, or with that of others, nor indeed 
where, in pursuance of my invitation, several inventors have applied 
their apparatus in my wards. I have examined, more than once, per- 
sons declared cured without shortening, and yet, upon measurement, 
the shortening was always manifest. The misfortune of all those who 
believe that they have obtained those miraculous cures is, that they 
have not even thought of instituting a comparative measurement of 
the two limbs ; I will say even more, that they are most generally 
ignorant of the conditions of a good and faithful measurement. 
Sometimes, also, they have been deceived in another way — in falling 
upon fractures which were not displaced, especially with young per- 
sons; and they have believed that they have cured with their appara- 
tus a shortening which had never existed. In short, when the frag- 
ments are not displaced, or even when they are brought again into 
a contact maintained by their reciprocal denticulations, it is easy to 
cure the fracture of the femur without shortening ; aside of those two 
conditions, the thing is simply impossible. 

" Several distinguished surgeons of our day have acknowledged this 
impossibility, and have renounced, in consequence, permanent exten- 
sion. They allege, moreover, that an overriding of even three centi- 
metres is of little importance, and occasions no limping. I cannot 
agree with this opinion. I have seen persons walk very well with a 
shortening of one centimetre ; beyond this limit, either they limp, or 
they have lifted the heel of the shoe, or, in short, the limping is only 
concealed by a lateral deviation of the spine. 1 We thus are made to 
comprehend how a fracture with overlapping is always serious, and 
how cautious we ought to be in our prognosis." 2 

That the foregoing remarks are intended by the author to be equally 
applicable to other fractures of the shaft of the femur than to those of 
the middle third, is made evident by what he has said before, when 
speaking of fractures of the upper third. 

"The prognosis is sufficiently favorable when the fragments are 

1 Dr. Buck, of New York, thinks that with a shortening of one inch, or even one 
inch and a half, the patient may have " a useful limb, with little or no halting in his 
gait." N. Y. Journ. of Med., vol. xvi. p. 294. 

2 Traite des Fractures et des Luxations, par J. M. Malgaigne, torn, prein., pp. 723, 
724. Paris, 1847. 



400 FRACTURES OF THE FEMUR. 

denticulated (engrenees) : when they ride, on the contrary, we must 
look for a shortening as almost inevitable." 1 

Mr. Holthouse says 2 that in 1857 he examined all the fractured 
thighs then under treatment in the different hospitals in London, and 
in the case of adults all were shortened except three, and he thinks 
it doubtful whether in these three cases his examinations were of any 
value. In thirty-five examples the average shortening exceeded one 
inch. In the case of children 40 per cent, were shortened. 

In our own country several of the most distinguished surgeons have 
testified to the constant difficulty, if not impossibility, of curing frac- 
tures of this bone without a shortening. In a suit instituted against 
a surgeon in New York city, for alleged malpractice in the treatment 
of an oblique, comminuted, and otherwise complicated fracture of the 
femur near its condyles, Dr. Mott is reported to have testified that 
"more or less shortening of the limb is uniformly the result after 
fractured thigh, even in the most favorable circumstances." 3 

In a very interesting communication made to the author by Jona- 
than Knight, of New Haven, late President of the American Medical 
Association, occurs the following passage : — 

" I have seen but few fractures of the femur in the adult, unless of 
the most simple kind, in which there was not some remaining de- 
formity ; often slight, so as not to impair the usefulness of the limb, 
and in others considerable and apparently unavoidable." Dr. Knight 
adds, however : " In the greater proportion of the fractures in children 
the recovery has been so nearly perfect that no marked deformity or 
lameness has followed." 

Dr. Detmold, in his remarks made before the New York Academy 
of Medicine, at its meeting in March, 1855, declared his belief that a 
shortening of the femur always occurs after fracture, and that " but 
one inch of shortening in an average of twenty cases is a good result." 4 

Dr. J. Mason Warren, of Boston, writes to me as follows : " As you 
are making observations on fractures, I would state that, after a long 
and very careful observation, I have never yet seen, either in Boston 
or elsewhere, an oblique fracture of the thigh, in a patient over seven- 
teen years of age, in which there was not some shortening. I have 
had cases shown to me in which it was averred that the limb was not 
shortened, but on measuring myself I have found the fact otherwise. 
In children, I believe that union without shortening may be accom- 
plished." 

In a paper published by Dr. Lente in the number of the New York 
Journal of Medicine for September, 1851, he states that he believes 
the average shortening after treatment in the New York City Hospi- 
tal to be three-quarters of an inch; but subsequently, Dr. Buck, one 
of the hospital surgeons, has furnished Dr. Lente with more exact 
statistics. Says Dr. Buck : — 

1 Op. cit., p. 718. 

2 Holthouse, Holmes' System of Surgery. London, 1861. vol. ii. p. 613. 

3 Boston Med. and Surg. Journ., vol. xxxiv. p. 450. See also opinions of Drs. Reese, 
Post, Parker, Cheeseman. Wood, &c, in relation to the prognosis in this particular 
ca<e. 

4 New York Journ. of Med., second series, vol. xvi. p. 261. 



FRACTURES OF THE SHAFT OF THE FEMUR. 401 

" After carefully scrutinizing over one hundred cases of fracture of 
the femur, taken from the register of the N. Y. Hospital, and elimi- 
nating such as involved the cervix, or condyles, or belonged to the 
class of compound fractures, there remained an aggregate of seventy- 
four cases, of both sexes, and of all ages from 3 to 63, in which the 
shaft of the femur alone was fractured. In all these cases the differ- 
ence in the length of the fractured limb, resulting from the treatment, 
was ascertained by careful measurement with a graduated tape, and 
the following deductions were drawn from the analysis : — ■ 

" Of the 74 cases of all ages, 19 resulted without any shortening, a 
proportion of about one-fourth. The average shortening of the re- 
maining 55 cases was a fraction less than f of an inch. 

" Seventeen cases in the above aggregate were under 12 years of 
age, of which six resulted without any shortening, a proportion of 
about one- third. The average shortening in the remaining 11 cases 
was a fraction less than one-half an inch. 

" Of the 57 cases over 12 years of age, 13 resulted without any 
shortening, a proportion of about one-fourth ; and the average short- 
ening in the remaining 44 cases was a fraction over j of an inch." 1 

It is not to be denied, however, that a few surgeons in all parts of 
the world have claimed, and still continue to claim, in their own prac- 
tice, or from the adoption of their own peculiar plans of treatment, 
much better success. Indeed, some of them do not hesitate to affirm 
that, as a general rule, any degree of shortening is quite unnecessary. 

Mr. Amesbury declares, that when the fracture is in the "middle 
or lower third," under a "judiciously managed" application of his own 
splint, "consolidation of the bone takes place without the occurrence 
of shortening of the limb, or any other deformity deserving of par- 
ticular notice." 2 

Mr. South, in a note, commenting upon an opposite sentiment ex- 
pressed by Chelius, and already quoted, remarks : "In simple fractures 
of the thigh-bone, except with great obliquity, I have rarely found 
difficulty in retaining broken ends in place, and in effecting the union 
without deformity, and with very little, and sometimes without any, 
shortening. For the contrary results the medical attendant is mostly 
to be blamed, as they are usually consequent upon his carelessness or 
ignorance." 3 

Mr. Hunt, of the Queen's Hospital, at Birmingham, who treats all 
fractures with the apparatus immobile of Seutin, has published the 
results of his observations ; and of the simple fractures of the femur 
only one presented, after the cure, any degree of shortening ; and he 
adds that all other fractures which he has treated by this method 
were followed by " equally good results." 4 In relation to which state- 
ments, Mr. Gramgee exclaims : " This is conservative surgery. What 

1 Buffalo Med. Journ., vol. xv. p. 22, June, 1859. 

2 Practical Remarks on Fractures, by Joseph. Amesbury, vol. i. p. 384. London ed., 
1831. 

3 Op. cit., vol. i. p. 627. 

4 Researches on Pathological Anatomy and Clinical Surgery, by Joseph Sampson 
Gamgee. London ed., pp. 159, 160. 



402 F'RACTUKES OF THE FEMUR. 

other mode of treatment would have given such results ? And those 
cases are not exceptional. Mr. Hunt tells us he has selected them 
from amongst many others equally successful. They accord with the 
experience recorded in my little treatise on this subject ; and the works 
of Seutin, Burggrseve, Crocq, Velpeau, and Salvagnoli Marchetti 
record numerous cases no less remarkable and demonstratively con- 
clusive." 1 

Desault, also, according to the passage from Malgaigne which I 
have already quoted, " pretended to cure all fractures without short- 
ening." I do not find, however, any other authority for this state- 
ment, as here made ; neither in his Treatise on Fractures and Luxa- 
tions, edited by Bichat, nor elsewhere. Bichat even says positively 
that " Desault himself did not always prevent the shortening of the 
limb." 2 He declares, however, that " Desault has cured, at the Hotel 
Dieu, a vast number of fractures of the os femoris, without the least 
remaining deformity." 3 

Dr.' Dorsey, of Philadelphia, who employed the apparatus of Desault, 
as modified by Physick and Hutchinson (Fig. 131), was equally suc- 
cessful. 4 

Fig. 131. 




Physick's Splint. — The splint is intended to reach to the axilla, but the counter-extension is made by 
a perineal band. Physick employed a second, long, inside splint. 

Dr. Scott, of Montreal, Prof, of Clinical Surgery in the McGill 
College, and Physician to the Montreal General Hospital, has reported 
19 cases of fractures of the long bones, taken promiscuously and 
without selection, from his hospital service, of which 3 belonged to 
the clavicle, 7 to the femur, 8 to the tibia and fibula, and 1 to the 
condyles of the humerus. All of which recovered without any degree 
of shortening or deformity ; except the case of fracture of the condyles 
of the humerus, which resulted in death. 5 

It is never a pleasant duty to call in question the accuracy of 
another's statements as to what he has himself alone seen and expe- 
rienced. The circumstances which would justify such an expression 
of scepticism, where the witnesses, as in this case, are presumed to be 
intelligent and honest men, must be extraordinary. Such, however, I 
conceive to be the circumstances in this instance. It is certainly very 
extraordinary that a few gentlemen of acknowledged skill, but whose 
means and appliances are concealed from no one, are able to do what 
nearly the whole world besides, with the same means, acknowledges 
itself unable to accomplish. Such is the fact, nevertheless ; and our 

i Op. cit., p. 167. 

2 A Treatise on Fractures and Luxations, etc., by P. J. Desault, edited by Xav. 
Bicbat. Amer. ed., p. 251. 1805. 
» Op. cit., p. 223. 

4 Elements of Surgery, by Jobu Syng Dorsey, vol. i. p. 163. Philadelpbia, 1813. 

5 " Medical Chronicle" of Montreal, vol. i. No. 7, 1853. 



FKACTURES OF THE SHAFT OF THE FEMUR. 403 

lack of faith in their testimony is only a necessary result of our expe- 
rience, and of the experience of the vast majority of practical surgeons, 
as opposed to theirs. 

I might properly enough dismiss this subject with no further argu- 
ment than may be found in the overwhelming testimony of practical 
surgeons, that broken femurs do in their experience rarely unite with- 
out more or less shortening ; but I cannot avoid calling attention to 
the evidence of the falsity of the opposite opinion, which is furnished 
by the testimony of the very persons who themselves claim to have 
obtained such fortunate results. 

It is not, as might have been supposed, one particular form of dress- 
ing, which, in itself peculiar, and more perfect than all others, has fur- 
nished these results, On the contrary, the plans of treatment have 
been constantly unlike, and sometimes quite opposite. Thus, Desault 
used a straight splint, with extension and counter-extension, and he 
refused to adopt the flexed position recommended by Pott, because 
his experience, and the experience of other French surgeons, had 
taught him its inutility. 1 Adopting the straight position, he made 
perfect limbs; with the flexed position, he found it impossible to 
do so. 

Dorsey used the splint of Desault, as modified by Physick and 
Hutchinson. 

South, whose success seems to have been equal to that of Desault 
or Dorsey, adopts also the straight position ; but he makes no perma- 
nent extension, except what may be accomplished through the medium 
of four long side splints applied after " gentle" extension has been 
made by the assistants. 

Mr. Amesbury, on the other hand, made perfect limbs only with his 
own double inclined plane ; and speaking in general of the various 
plans hitherto contrived, not excepting that invented by Desault, or 
the method practised by South, which had already been recommended 
by several surgeons, he declares that " they are seldom able to prevent 
the riding of the bone, and preserve the natural figure of the limb. 
Indeed, so commonly does retraction of the limb occur under the use 
of the different contrivances usually employed, that I have heard a 
celebrated lecturer (now retired) in this town publicly assert that he 
never saw a fractured thigh-bone that had united without riding of 
the fractured ends !" 2 And in his " General Inferences 11 he uses the 
following emphatic language : " The contrivances which are com- 
monly used in the treatment of these fractures do not sufficiently 
resist the operation of the forces above mentioned, but suffer their 
influence to be exerted upon the bone, in all cases more or less inju- 
riously, and at the same time often assist in producing displacement of 
the fractured ends ; so that deformity, differing in kind and degree in 
different cases, is almost the constant result of fractures of the femur 
treated by these means." 3 

While Mr. Gramgee thus broadly contradicts the statements of 

■ Works of Desault. Op. cit., p. 225. 

2 Amesbury on Fractures, &o., vol. i. p. 310. 3 Op. cit., vol. i. p. 384. 



404 



FRACTURES OF THE FEMUR. 



Desault, South, Dor*sey, and Amesbury, he administers a severe 
rebuke even upon the illustrious Liston : " Pott's plan, the long splint, 
Mclntyre, and their modifications, as a rule entail sensible deformity, 
which in many cases is very considerable. It is a significant fact that 
though the example established in University College Hospital by the 
late Mr. Liston, of treating fractures of the thigh by long splint (Fig. 
132), and of the leg by the modified Mclntyre, which are admitted 
equal, if not superior, to other splints, was rigidly followed in that in- 
stitution, the patients admitted with broken thighs or legs were fre- 
quently discharged with manifest deformity." 1 

With how much force his own remarks as to the experience of the 
University College Hospital will apply to the starched bandages used 
by himself, the reader will be able to determine when referred to the 
opinion of Yelpeau, already quoted, who claims no result better than 
an average shortening of half an inch. It is true, however, that M. 
Yelpeau prefers and advocates the starched bandage, but it is not true 
that he claims to be able to prevent a shortening of the bone. 

Fig. 132. 




Liston's method, recommended by Samuel Cooper, Fergusson, Pirrie, and others. 

""What other modes of treatment would have given such results?" 
This question, propounded, no doubt honestly, by Mr. Gamgee, has 
here its fair and satisfactory answer. Almost any of the various 
modes named ; for if we must receive his testimony, we are equally 
bound to receive the testimony of Desault, South, Dorsey, Amesbury, 
and Scott. If we give credit to Mr. Gamgee, so far as to doubt the 
statements of these latter as to the degree of success claimed by them, 
by the same rule we must doubt his own statements also as to the 
degree of success claimed by himself. This I say with all sincerity 
and kindness, fully believing that these gentlemen are mistaken, and 
not that they intentionally misrepresent the facts. 

By a reference to my " Keport on Deformities after Fractures," it 
will be seen that the average shortening in fractures of the upper third 
of the femur, in the cases examined by me, was about four-fifths of an 
inch ; in the lower third it was a fraction over three-quarters, and in 
the middle third a fraction less than three-quarters of an inch ; and 
the average of the whole number was almost exactly three-quarters 
of an inch (three-quarters and -^). These analyses were made upon 
simple fractures, and were exclusive of those in which no shortening 
at all occurred. An analysis which included also those which had 



1 Advantages of the Starched Apparatus, by Joseph Sampson Gamgee. 
1853, pp. 54, 55. 



London, 



FEACTUEES OF THE SHAFT OF THE FEMUE. 405 

not shortened, reduced the average shortening to half an inch and 
about one-tenth. 

An examination of cabinet specimens does not present a result so 
favorable even as this. Of nineteen fractures of the shaft of the femur 
contained in Dr. Mutter's cabinet, not one seems to have been short- 
ened less than one inch. Specimen B 63, fracture of the middle 
third, is united with a shortening of two inches and a quarter ; and 
specimen B 130, imperfectly united after a fracture through the mid- 
dle third, is overlapped three and a half or four inches. 

In conclusion, I wish to say briefly that, in view of all the testimony 
which is now before me, I am convinced — 

First. That in- the case of an oblique fracture of the shaft of the 
femur occurring in an adult, whose muscles are not paralyzed, but 
which offer the ordinary resistance to extension and counter-extension, 
and where the ends of the broken bone have once been completely 
displaced, no means have yet been devised by which an overlapping 
and consequent shortening of the bone can be prevented. 

Second. That in a similar fracture occuring in children or in per- 
sons under fifteen or eighteen years of age, the bone may sometimes 
be made to unite with so little shortening that it cannot be detected 
by measurement ; but whether in such case there is in fact no short- 
ening, since with children especially it is exceedingly difficult to 
measure very accurately, I cannot say. 

Third. That in transverse fractures, or oblique and denticulated, 
occurring in adults, and in which the broken fragments have become 
completely displaced, it will generally be found equally impossible to 
prevent shortening ; because it will be found generally impossible to 
bring the broken ends again into such apposition as that they will rest 
upon and support each other. 

Fourth. That in all fractures, whether occurring in adults or in 
children, where the fragments have never been completely or at all 
displaced, constituting only a very small proportion of the whole 
number of these fractures, a union without shortening may always be 
expected. 

Fifth. That when, in consequence of displacement, an overlapping 
occurs, the average shortening in simple fractures, where the best 
appliances and the utmost skill have been employed, is about three- 
quarters of an inch. 

If we consider the muscles alone as the cause of the displacement 
in the direction of the long axis of the shaft, the shortening of the 
limb, other things being equal, must be proportioned to the number 
and power of the muscles which draw upwards the lower fragment. 
This will vary in different portions of the limb, but nowhere will this 
cause cease to operate, nor will its variations essentially change the 
prognosis. 

I have not intended to say that other causes do not operate occa- 
sionally in the production of shortening, but only that muscular con- 
traction is the cause by which this result is chiefly determined, and 
that its power will be ordinarily the measure of the shortening. 

Treatment. — All the early surgeons, so far as we know, adopted 



406 



FRACTURES OF THE FEMUR, 



the straight position in the treatment of fractures of this bone ; either 
with simple lateral splints, or with long splints, with or without exten- 
sion, or with only rollers and compresses, or with extension alone. 

Such was the unanimous opinion and practice of surgeons until 
about the middle of the last century, at which time Percival Pott wrote 
his remarkable treatise on fractures; a work distinguished for the origi- 
nality and boldness of its sentiments, and which was destined soon to 
revolutionize the old notions as to the treatment of fractures, and to 
establish in their stead, at least for a time, what has been called, not 
inappropriately, the " physiological doctrine ;" the peculiarity of which 
doctrine consisted in its assumption that the resistance of those muscles 
which tend to produce shortening can generally be - sufficiently over- 
come by posture, without the aid of extension ; and that for this pur- 
pose, for example, in the case of a broken femur, it was only necessary 
to flex the leg upon the thigh, and the thigh upon the body, laying the 
limb afterwards quietly on its outside upon the bed. 

Yery few surgeons, even of his own day, ever gave in their full ad- 
hesion to the exclusive physiological system as taught and practised 
by Pott himself; but multitudes, especially among the English, adopted 
in general his views, only choosing to place the patients upon their 
backs rather than upon their sides, and laying the limbs flexed over a 
double inclined plane. To the support of this system of Pott's, thus 



Fig. 133. 




Double inclined plane employed in Middlesex Hospital, London. 

modified, Sir Astley Cooper, C. Bell, John Bell, Earle, White, Sharp, 
and Amesbury, lent the influence of their great names, and its triumphs, 
so far as the judgment of British surgeons was concerned, soon became 
complete. 

Fig. 134. 




Amesbury's splint. 



In France, and upon the continent generally, the reception of this 
system was more slow and reluctant ; but Dupuytren now for once 



FRACTURES OF THE SHAFT OF THE FEMUR. 



407 



taking ground with his great rival, Sir Astley, adopted almost without 
qualification these novel views. The decision of Dupuytren deter- 

Fig. 135. 




Amesbury's splint applied. 

mined the opinions of a large portion of the continental surgeons; 
and had it not been for the early and decisive opposition of Desault 
and Boyer, the great surgeon of St. Bartholomew might have con- 
tinued for a long time to have enjoyed a triumph upon the continent, 
and perhaps throughout the world, equal to that which had already 
been decreed to him in Great Britain. 



Fig. 136. 




Boyer's splint. 

On this side of the Atlantic, the practice of Pott, at least in so far 
as it applied to the treatment of fractures of the thigh, never gained 
a distinguished advocate ; and but few ever adopted the practice as 
modified by White, Amesbury, Bell, A. Cooper, &c. 

But whatever may have been the early success of these doctrines, 
either here or elsewhere, it is certain that a strong reaction has taken 
place, and that gradually, in all parts of the world, the opinions of 
practical surgeons have been settling back into their old channel. It 
would be difficult to find to-day, in France, a dozen distinguished sur- 
geons who adopt universally the flexed position in the treatment of 
fractures of the femur ; and in England the reaction is, if possible, 
even more complete. 

In my tour of 1844, during which I visited very many of the hos- 
pitals of Great Britain and upon the continent of Europe, I do not 
remember to have seen the flexed position once employed in the treat- 
ment of a broken thigh ; and I shall presently show that the straight 
position is at the present moment very generally adopted by the best 
American surgeons. 

There have been, then, three grand epochs in the history of the 
treatment of fractures of the thigh. 



408 



FBACTUBES OF THE FEMUR. 



First. That in which the straight position was universally adopted, 
and which reaches from the earliest periods to the period of the writ- 
ings of Pott, or to about the middle of the last century. 

Second. The epoch of the flexed position, which, inaugurated by 
Pott, had already begun to decline at the beginning of the present 
century, and which may be said to have been completed within less 
than one hundred years from the date of its first announcement. 

Third. The epoch of the renaissance, or that in which surgeons, by 
the vote of an overwhelming majority, have declared again in favor 
of the straight position. This is the epoch of our own day. 

Although American surgeons have generally adopted the straight 
splint in the treatment of fractures of the thigh, yet the form and 
construction of the splint have been greatly varied. The simple long 
splint of Desault, and the more complicated apparatus of Boyer (Fig. 
136), have each their advocates ; but it is seldom that we meet with 
these, or with any of the other forms of apparatus originally employed 
in foreign countries, without noticing that they have been subjected 
to considerable modifications ; indeed, most of the straight splints as 
well as double inclined planes in use at present among American sur- 
geons may fairly be regarded as original inventions. 

Nathan Smith, of New Haven j 1 Nathan E. Smith, of Baltimore ; 2 
Nott, of Mobile ; 3 McNaughton, of Albany ; 4 and Valentine Mott, of 

Fig. 137. 




Nathan R. Smith's suspending apparatus, or donble inclined plane. 

New York, are the only American surgeons of distinguished reputa- 
tion, and with whose practice I am familiar, who recommend exclu- 
sively the double-inclined plane ; and perhaps we have a right to infer 
from the following paragraphs, copied from a letter addressed to the 
author a few years since, that the opinions of Dr. Mott have undergone 
some modification in view of the improvements recently made in the 

1 Amer. Med. Rev., published at Philadelphia, 1825, vol. ii. p. 355 ; also Medical 
and Surgical Memoirs of Nathan Smith, published at Baltimore, pp. 129-141. 

2 Med. and Surg. Memoirs, pp. 143-162. See also G-eddings, Baltimore Med. and 
Surg. Journ., vol. i. 1833; and Sargent's Minor Surgery, p. 171. 

3 Amer. Journ. Med. Sciences, vol. xxiii. p. 21. 

4 Trans. Amer. Med. Assoc, vol. x. p. 317. Rep. on Defor. after Frac. 



FRACTURES OF THE SHAFT OF THE FEMUR. 409 

construction of straight splints, and in the means of extension and 
counter-extension. 

Fig. 138. 




Josiah C. Nott's Double Inclined Plane. 
In this apparatus the limb is secured to the splint by vertical pins and leather straps ; the upper sur- 
face of the thigh splint is carved out a little, to fit the thigh: the two portions are articulated by a joint 
like that of a carpenter's rule, and this joint may be steadied by a horizontal bar underneath. For the 
rest, the drawing sufficiently explains itself. 

" Many years since I introduced into the New York Hospital Boyer's 
long splint, and continued to use it there and in private practice for a 
long time. I found, however, in many cases, that I had more or less 
trouble at the foot and groin from the points of extension and counter- 
extension. I then gradually laid it aside, and for some years have 
again taken up the double inclined plane. 

" From the abundance which I have seen, I am free to say that, if I 
had my own femur broken, I would be treated upon the double in- 
clined plane. 

"The Drs. Burges, brothers, Court St., Brooklyn, Long Island, have 
made an improvement upon the extended principle (Figs. 141, 142). 
Their apparatus is now complete, and is in use at the Bellevue Hos- 
pital, where I advised, some time since, that it should be tried. It has 
succeeded admirably in two cases." 

Dr. Nathan K. Smith has introduced another modification of the 
double inclined plane in what is known as his " anterior splint," and 
which is intended also as a suspending apparatus. I have seen it 
employed lately a good deal in the treatment of gunshot fractures of 
the thigh and leg in our various military hospitals. It is my opinion, 
however, that it is more applicable to gunshot fractures of the leg 
than to those of the thigh. 

The splint, if splint it can be properly called, is simply a frame 
composed of stout wire and covered with cloth, which being suspended 
above the limb, allows the limb to be suspended in turn to it by rollers; 
the rollers passing around both limb and splint from the foot to the 
groin. Wire of the size of No. 10 bougie is usually employed. The 
length of the splint should be sufficient to extend from above the 
anterior superior spinous process of the ilium to a point beyond the 
27 



410 



FRACTURES OF THE FEMUR. 



toes, the lateral bars being separated about three inches at the top and 
one-quarter of an inch less at the lower extremity. 

Fig. 139. 




N. E. Smith's anterior splint. 

In the case of a broken thigh, the upper hook, to which the cord 
for suspension is to be fastened, ought to be nearly over the seat of 
fracture, and the lower hook should be placed a little above the middle 
of the leg. 

Fig. 140. 




N. R. Smith's anterior splint, applied for a fracture of the thigh. 



Dr. J. T. Hodgen, of St. Louis, Mo., has invented a similar wire 
suspension splint, which I much prefer. The bars of wire are 
traversed with a cotton sacking, upon which the limb is laid. He 
does not, however, advocate its general use, but he has designed it 
especially for gunshot fractures. 1 

On the other hand, among the advocates of the straight position 
are found the names of Physick, Dorsey, Gibson, Horner, J. Harts- 
horne, H. H. Smith, Neill, R. Coates, H. Hartshorne, Norris, Gross. 

Says Dr. Gross : " Many years ago, before I had much experience in 
this class of injuries, I occasionally employed the flexed position, but 
I soon found that it was objectionable, on account of the great difficulty 
in maintaining so accurate apposition to the ends of the fragments. Of 
late years I have confined myself entirely to the use of the straight 

» Hodgen, Treatise on Mil. Surg., by F. H. Hamilton, 1865, p. 411. 



FRACTURES OF THE SHAFT OF THE FEMUR, 
Fig. 141. 



411 




Burge's Apparatus. 
Fig. 142. 




Burge's Apparatus applied. 

"A. Thick mattress. B. Thin mattress. 0. Wooden platform upon which the thin mattress is laid. 
This platform is made in two pieces and hinged together so as to fold upon itself for convenience of trans- 
portation, and when in use is merely hooked upon the central platform D. 

" D. Central or cushioned platform supported at either end hy wooden strips marked E, which rest 
upon F, a second platform of same extent as D. This constitutes a shelf for the hed pan, which may 
be introduced below from either side. 

" G. Hair cushion, upon which the hips of the patient rest. This cushion, as well as the platform D, 
to which it is buttoned, has a semicircular opening at its lower margin for convenience of defecation. 

" H. A rectangular wooden slide, exactly corresponding to its fellow upon the opposite side of the 
pelvis. These slides are so arranged upon the platform D as to be separated or approximated at will, 
and, by a' thumb-screw which passes through a fissure in the horizontal portion of each, they may be 
fixed at the desired point so as exactly to embrace the pelvis of any patient. There is also a fissure in 
the perpendicular portion of each rectangular slide, and a screw passing through the same. One of these 
is to secure the upper end of the long splint J, and the other for the attachment of a short splint /, upon 
the side of the pelvis corresponding to the uninjured limb. Both of these splints are well padded upon 
one surface, and may be elevated or depressed at will, in order to bring them to the level of the limbs, 
and fixed at the proper altitude by the screws already mentioned. They are also mutually transferable, 
thus adapting the apparatus to fractures of either thigh. 

" SS. Counter-extending pads. These are attached by leather straps to the upper surface of the plat- 
form D, about twelve inches apart. Passing under the cushion G, and becoming well-rounded pads, they 
traverse the tuberosities of the ischia, pass between the thighs and thence perpendicularly to the hori- 
zontal iron rod or crossbar L. The crossbar L is supported at each end by a perpendicular bar extend- 
ing upwards from the platform D. Attached by one extremity to the crossbar L is a rod P, runniug 
parallel with and situated directly above the thigh. The other end of this rod P is supported by an 
arched iron bar N, extending upwards from the outer side of the long splint J. The rod P is designed to 
afford special support to the injured limb whenever such support is deemed advisable. Two or three 
strips of cotton cloth, of suitable width, may be passed around the limb, either internally or externally 
to the splints of coaptation, and tied over the supporting rod P. Splints of coaptation are to be applied 
according to ihe exigencies of the case. 

" M. An inside splint covered by the bandages. Q. The screw by which extension is effected in the 
ordinary way, having at one extremity a swivel and hook tied to a strip of wood in the loop of adhesive 
plaster below the foot." 



412 



FRACTURES OF THE FEMUR. 



position, and I have never bad any cause to regret it. In the adult, I 
sometimes employ the apparatus of Desault, as modified by Physick, 
but much more frequently one of my own construction, somewhat 
upon the principle of that of Dr. Neill, described in the Philadelphia 
'Medical Examiner for 1855. I have used it for nearly twenty years, 
and it has generally answered the purpose most admirably in my 
hands. It consists simply of a box for the thigh and leg, with a foot- 
piece, and two crutches, one for the axilla and the other for the peri- 
neum, to make the requisite extension and counter-extension. With 
such an apparatus, an oblique fracture of the thigh can be treated with 
great comfort to the patient, and with the assurance of a good limb. 
In children, I have effected some excellent cures simply by means of 
a sole-leather trough, well padded and provided with a foot-piece. 

Fig. 143. 




John Weill's Straight Thigh-Splint. — Extension and counter-extension made at the same moment. 

" The great objection to the flexed position is the difficulty of keep- 
ing the ends of the broken bones in apposition; the upper one having 



Fig. 144. 



Fig. 145. 





Pelvic belt, and perineal strap. (From draw ings fur- 
nished by Dr. L. M. Sargent, Boston, Mass.) 



Foot-piece and screw 



a constant tendency to pass away from the inferior. Other objections 
might be urged against the flexed position, but this is quite sufficient 
to induce me to reject it." 1 



• Trans. Am. Med. Assoc, vol. x.; also System of Surg., by S. D. Gross, 1859, p. 221. 



FKACTUEES OF THE SHAFT OF THE FEIUK. 



413 



Dr. Neill, of Philadelphia, has contrived a very ingenious mode of 
making both extension and counter-extension at the same moment by 

Fig. 146. 




Front view, with folded sheet laid across. 
Fig. 148. 




^M^^^Wf^^l 



Side view of apparatus applied. 




Fig. 151. 




Figs. 150, 151. Mode of making extension with adhesive plaster. 

means of a twisted rope which is fastened by its two ends respectively 
to the perineal band above and the extending bands below. 



4U 



FRACTURES OF THE FEMUR. 



J. F. Flagg's thigh apparatus, as used iu the Massachusetts General 
Hospital, by Warren, Bigelow, and others (Figs. 148 to 156 inclusive). 



Fig. 152. 




Fig. 153. 



Perineal band secured with a padlock. 

" The belt is made of strong webbing, having 
pockets on each side, to receive the long splint. 
It is also furnished with straps and buckles. 
The perineal strap (Fig. 152), corresponding to 
the injured side, is kept constantly buckled, 
while the other may be occasionally loosened, 
or left off, as its purpose is only to steady the 
apparatus. Where the straps pass under the 
perineum, they are covered with wash-leather. 
Before applying the belt, a pillow-case or two 
may be passed around the waist. The padlock 
is only to be used in case the patient persists in 
unbuckling the straps. The splints being ap- 
plied with also short side splints, junks, contain- 
ing bran or sand, &c, are to be secured more 
firmly to the limb by bands of webbing and 
buckles." 

The two Warrens, father and son, of Boston, 
Kimball, of Lowell, Sanborn, of Lowell, Mass., 
Mussey, of Cincinnati, Ohio, J. B. Flint, of Louis- 
ville, Ky., Armsby, of Albany, 1 also recommend 
some form of the straight splint. Says Dr. Mus- 
sey :— 

" For all fractures of the thigh-bone I employ 
the extended position of the limb. There are but few cases in which 
extending force is not necessary to prevent the degree of deformity or 
shortening which would occur without it. Of thirty specimens of 
fracture of the shaft, in my collection, only two are transverse. In 
fractures of the neck, especially with old subjects, I sometimes avoid 
the application of any kind of apparatus for permanent extension ; but 
in all cases, whether of the neck or shaft, where such extension is at- 




Saxbors's Splint, a. The 
movable crutch, b. The 
screw which fixes the 
crutch, e. The cross-bar 
to which the ends of the 
strap are fastened, d. The 
moving screw. 



Trans. Am. Med. Assoc, vol. x. Report on Deformities after Fractures. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



415 



tempted, I have found the straight position of the limb to be the most 
reliable.' 1 

And Dr. Kimball, who employs generally Sanborn's splint, uses the 
following emphatic language: — 

" If I should be asked under what circumstances I would use the 
double inclined plane in case of fracture of the femur, I would unhesi- 
tatingly answer, never ! I have long since abjured the double in- 
clined plane in every form of fracture, of this bone, finding the straight 
splint fully adequate to all purposes for which any apparatus of this 
kind is required. In support of this statement, I could furnish a 
great number of cases showing that the locality of the fracture, the 
importance of which is so much dwelt upon in the books, constituted 
in no case a valid objection to its use." 

Extension in Sanborn's apparatus is effected by means of adhesive 
straps, and counter-extension by a perineal band ; but the patient 
may at any moment relieve the pressure in the perineum by resting 
his axilla upon the head of the crutch. 

Daniell, of Savannah, Georgia, recommends the straight position, the 
limb being laid in a kind of long box, and the extension being made 
with a weight and pulley. 1 Dugas, of Augusta, Georgia, employs the 
pulley and weight also, but uses the long side splint instead of the 
box. 2 Howe, of Boston, recommended a similar method in 1824. 3 

Dr. Gurdon 0. Buck, of the New York City Hospital, uses the 
pulley, without the long side splint. His perineal band is composed 
of India-rubber tubing, "of one inch calibre, two feet in length," 
stuffed with bran or cotton lampwick, and covered with canton flannel, 
which covering may be renewed as often as may be necessary. The 
extending bands or adhesive plasters terminating below the foot in 

Fig. 154. 




Gurdon Buck's apparatus. 

an elastic rubber cord. The weight necessary to make suitable ex- 
tension will vary from five to twenty pounds. 



1 Amer. Journ. Med. Sciences, vol. iv. p. 330, 1829. 

2 Southern Med. and Surg. Journ., Feb. 1854. 

3 Howe, New Eng. Med. Journ., July, 1824. 



416 



FRACTURES OF THE FEMUR. 



At Bellevue, where we "use the pulley and weight a good deal, I 
seldom employ the perineal band as a means of counter-extension, ex- 
cept in the case of children, relying altogether upon the weight of the 
body for this purpose ; the foot of the bedstead being elevated always 
about four inches. With children, and especially with very young 
children, this method is insecure ; and the long double splint, inclosing 
both thighs (Fig. 170), is the only apparatus which I have found 
reliable. It is not necessary to use the complicated screw described 
in connection with that apparatus, as the weight and pulley are equally 
applicable in this form of splint. The perineal band is also, in the 
case of children, regarded by me as indispensable. 

Wm. E. Horner, of Philadelphia, employed a long outside splint 
(Fig. 155. a), extending into the axilla, and padded, so as to avoid the 
necessity of junks ; with fenestras, for extending and counter-extending 
bands ; and also a foot-piece ; and a short inside splint (b), made to 
extend from the perineum to the bottom of the foot. Across the ex- 
Fig. 155. 




W. E. Horner's thigh-splint. 

cavated upper end of this splint, a strip of leather is stretched to 
receive the pressure of the perineum, while the perineal band is made 
to pass through two firm leather loops on the outside of the splint. 1 

Dr. Joseph E. Hartshorne, of Philadelphia, rejected the perineal 
band altogether, and sought to make the counter-extension by means 
of the internal long splint alone ; and for this purpose he cushioned 
the head of the inside splint, as will be seen in the accompanying 
drawing. The head of the outside splint may also be cushioned, but 

Fig. 156. 




Joseph Hartshorne's thigh splint. 

not for the purpose of employing it as a means of counter-extension. 
The outside splint is so adjusted to the foot-piece, that it may be re- 
moved" in case of a compound fracture, without disturbing either the 
extension or counter-extension. 2 

George F. Shrady, of New York, Act. Asst. Surgeon U. S. Army, 



Treatise on the Practice of Surgery, by Henry H. Smith. 



Ibid. 



FEACTUEES OF THE SHAFT OF THE FEMUE. 



417 



has lately devised a very simple and ingenious mode of suspending 
the thigh and leg. The apparatus is composed of strong iron bars 




George F. Shrady's suspending apparatus. 

bent as in the above drawing (Fig. 157, a), through which are passed 
two horizontal, sliding rods, the rods supporting two pieces of canvas 
upon which the limb may be suspended. The perpendicular bars are 
furnished each with a clamp and thumb-screw, by means of which, the 
bars may be made fast to the side rails of an iron bedstead, or, in case 
of necessity, to the sides of a stretcher. The clamps enable the sur- 
geon to suspend the limb at any height from the bed, and to give to 
the canvas bottom any degree of inclination desirable. 

The accompanying drawings (Fig. 158, 1, 2, 3, 4) represent a ygtj 
simple and easily-constructed apparatus devised by Dr. Alonzo Chapin, 

Fig. 158. 



o o 
o o 



p aa] 



'I 



anal 



*± """""4 



o o 

t r 



Alonzo Chapin's thigh apparatus. 

of Massachusetts, which has many points of real excellence. 1 It will 
serve at least to instruct the reader how he may furnish himself ex- 
temporaneously with a complete apparatus when he is not otherwise 
prepared. The iron screw and swivel for making extension can be 
made by any blacksmith in a few minutes. Dr. Chapin uses two of 

1 Amer. Journ. Med. Sci., April, 1859, p. 355. 



418 FRACTURES. OF THE FEMUR. 

these screws, but one would ordinarily answer the purpose equally 
well. By having the tenons in the side splints instead of in the foot- 
piece, the apparatus may be opened laterally and made to fit the sides 
of the limb more or less closely. 

There are many, however, of our most distinguished surgeons, who 
retain the flexed position in certain fractures, such as an oblique 
downward and forward fracture, occurring just below the trochanter 
minor, and a similar fracture just above the condyles, or in certain 
cases of fractures in children, or in very old people, but who, never- 
theless, give a decided preference to the straight splint in those oblique 
fractures of the shaft which constitute by far the greatest proportion 
of all these accidents. Among these, I will mention the names of 
Post, of New York, 1 De Lamater, of Cleveland, Ohio, 1 Pope, of St. 
Louis, Mo., 1 Knight, of New Haven, 1 and Eve, of Nashville, Tenn. 1 

Dr. Pope has given us his views upon this subject very much at 
length : — 

" In the treatment of fractures of the femur, I employ neither the 
straight nor the flexed position exclusively, but the one or the other, 
according to the site of fracture. If the fracture involves either the 
upper (below the trochanter minor) or the lower third (above the con- 
dyles) of the femur, I make use of the double inclined plane of Sir 
Charles Bell. If, on the other hand, the seat of fracture be in the 
middle third of the thigh, I greatly prefer the straight, long splint of 
Mr. Liston. 

" My reasons are briefly the following : In fractures below the tro- 
chanter minor, the upper fragment is tilted forwards and upwards, by 
the unrestrained action of the psoas muscle, so that no extension in 
the straight direction will avail to draw down the upper in a line with 
the lower portion of the lever. 

"The same thing results in fractures of the lower third, but in 
opposite directions. Here the heel becomes the fixed point, and the 
gastrocnemii draw the lower fragment backwards and downwards, 
whilst the upper fragment projects in front. Eectilinear extension 
can no more correct the malposition of the lower fragment in this case, 
than it can in the former that of the upper. But in both (upper and 
lower third fractures), by placing the limb over a double inclined 
plane, these otherwise insuperable deviations of the fragments are 
prevented, and the whole bone is brought into proper line. 

" When, on the contrary, the fracture implicates the middle third 
or even the middle half of the femur, I invariably employ the straight 
splint, which I regard as by far the simplest, most effectual, and best 
means of treatment ; and, indeed, but for the reasons assigned, I should 
only be too glad to use it exclusively in the management of all frac- 
tures of the thigh. 

" My cabinet presents several specimens of broken femurs which 
illustrate the soundness of these views : in which the abnormal direc- 
tion of the fragments alluded to as occurring in fractures of the upper 
and lower thirds, is very marked; the deformities having resulted 

1 Trans. Amer. Med. Assoc, vol. x. ; Rep. on Def., etc. 



FRACTURES OF THE SHAFT OF THE FEMUR. 419 

from treatment in the straight position. So far as function and sym- 
metry are concerned, the lower deformity is altogether the most serious. 
The unseemly projection above the knee, the unnatural exposure in 
front of the articular surfaces of the condyles, which are not set bluffly 
on those of the tibia, together with the altered site of the patella, and 
the diminished power of the quadriceps muscle, both weaken and 
deform the joint. 

" With regard to the management of fractures below the trochanter 

o o 

minor, or at other points of the femur, by means of the double in- 
clined plane, I am well aware of the difficulty of properly confining 
the pelvis, but this objection I am far from considering as insuperable. 
So, too, the outward tendency of the upper fragment, caused by the 
gluteus, may be humored by carrying the limb off at an oblique angle 
to the axis of the body. 

" It is, perhaps, needless to add, that in fractures of the condyles, of 
the inter-trochanteric portion, as well as of the neck of the femur (when 
osseous union is attempted), whether within or without the capsule, I 
likewise give preference to the straight position." 

The practice of Dr. Pancoast, of Philadelphia, is peculiar, and will 
be best described by himself: — ■ 

" I treat all thighs, fractured in their middle part, by the long splint, 
and in the straight position. In fractures occurring at either end of 
the bone, I resort at first to the angular splint and the flexed position, 
and thus place the muscles more at rest ; in which position, also, there 
is less tendency to angular displacement and shortening. After the 
lapse of a few days, when the disturbed muscles have lost their ten- 
dency to spasm, and the hardened cellular tissue about the fracture 
has formed a sort of bond between the ends of the broken bone, I 
gently bring the limb down to the straight position, and apply the 
long splint." 1 * 

The practice of treating fractures of the thigh, as well as all other 
fractures of the long bones, with the roller alone, and without either 
lateral splints or extending apparatus, first suggested by Radley, has 
found in this country but one distinguished advocate, Dr. Dudley, of 
Lexington, Ky. 2 Nor, with all my respect for that venerable and 
truly great surgeon, can I persuade myself that the practice is able to 
accomplish, in a majority of cases, the indications proposed, nor indeed 
that it is, at least in the hands of inexperienced surgeons, wholly safe. 
Dr. D., of Aberdeen, Miss., has reported to me one example in which, 
after the application of this bandage, by a pupil of Dr. Dudley's, to a 
negro slave, who had a fracture of the femur, death of the limb ensued, 
and amputation became necessary. The negro was sixteen years old, 
and healthy; the fracture was caused by the fall of a tree or of a 
branch, and was simple. The bandage was applied from the toes up- 
wards to the groin, and was not opened for several days, at which time 
the whole limb was found to be in a state of dry gangrene, with the 

1 Trans. Amer. Med. Assoc, vol. x. Rep. on Def., etc. 

2 Amer. Joum. of the Med. Sci., vol. xix. p. 270 ; Transylvania Journal, April, 
1836 ; Boston Med. and Surg. Journ., vol. xxxiv. p. 35. 



420 FRACTURES OF THE FEMUR. 

exception of the upper two-thirds of the thigh, which was swollen 
enormously, and partially gangrenous as high up as the groin. 

Dr. D. says: "Having heard the history of the case carefully stated, 
observing the leg and the lower part of the thigh to be in a state of 
dry gangrene, and seeing the marks of the bandage visibly impressed 
on the surface, my opinion was made up at the time that the gangrene 
had resulted from pressure of the bandage. The femoral artery at the 
oroin was in a sound and natural state, and, if I mistake not, after the 
limb, was removed, it was traced to the point of obliteration where 
the gangrene commenced, and where the impression of the bandage 
was observed ; thus far, I think, it was of natural size and calibre. 
Hence the conclusion is inevitable, that the death of the limb resulted 
from the pressure of the bandage, and not of one of the fragments. 

"It was a curious specimen of dry mortification, and I regret that I 
did not use the means of preserving it. I was then engaged in a very 
laborious practice, thirty miles from home, on horseback, and conse- 
quently could not conveniently spare the time to attend to it as an 
object of surgical curiosity. Dr. H. and myself cut into the leg in 
various places in order to examine the muscles, arteries, nerves, etc., 
but found the integuments so hard that it was really difficult to pene- 
trate them with a knife; the resistance to the knife was more like 
that of dry hickory wood than anything else." 1 

In relation to other plans of treatment, I shall content myself by 
declaring my belief that the starched bandage of Seutin, Yelpeau, 
Gamgee, and others, cannot be regarded as a safe or effectual appara- 
tus ; and that extension alone, without either side splints or long 
splints, which I have seen practised by Jobert, of Paris, and other 
French surgeons occasionally, is inefficient. Nor can I look any more 
favorably upon the ingenious plan devised and practised by my ta- 
lented countryman, Dr. Swinburne, of Albany, N. Y., and by which 
he also proposes to dispense with lateral splints altogether. 2 My re- 
marks hereafter will therefore be confined to a more full declaration 
of the principles involved in, and the proper mode of using the long 
splint. 

Without limiting ourselves to the consideration of any one of the 
special forms of apparatus, we may say that the following ought to be 
regarded as essential elements in the construction of the long straight 
splint (Fig. 165) : Length, sufficient to extend at least several inches 
above the ala of the pelvis, and the same distance below the foot ; 
such thickness as that it shall be firm and unyielding ; width, suffi- 
cient to make it serve as one of the lateral splints, since over all the 
more properly called lateral splints it possesses this advantage, that it 
can never become displaced downwards or upwards ; its width ought 
seldom to be less than three and a half inches, nor should its width 
diminish as it descends toward the foot, as, in consequence of this 
construction, the roller, which is intended to secure the limb to the 
splint, has a constant tendency to slide in the same direction. 

1 For a more complete account of this interesting case, see Buffalo Med. Journal, 
vol. xiv. p 193, Sept. 1858. 

2 Swinburne, Amer. Med. Times, vol. ii. p. 134, Feb. 1861; also p. 143. 



FEACTUKES OF THE SHAFT OF THE FEMUR. 421 

A foot-piece or transverse block, to which the foot may be attached 
for the purpose of making extension as nearly as possible in the axis 
of the limb. If this foot-piece is movable, it will serve only the single 
purpose above mentioned, and no rule need govern its width. But in 
this case there must be another block attached to the bottom of the 
long splint, at a right angle with the shaft, and of the same width as 
the splint ; the object of which will be to support and steady the side 
splint, and to prevent its rolling inwards or outwards. Where this 
is neglected, frequent disturbance of the broken fragments, and a 
deformity from inclination of the foot outwards or inwards, are apt to 
ensue. If the foot-piece is not movable, then it may be of the same 
width as the side splint, and serve both to steady the side splint, and 
as a means of extension. The length of the foot-piece ought not to 
be such as to interfere with a long inner splint, in case its use should 
be deemed advisable. With two fenestras placed at the upper part of 
the splint, for the reception of the counter-extending band, the long 
outside splint is now complete. 

* These are, so to speak, its simple elements, and compose the splint 
in its rudest form, without which no splint can be perfect, yet upon 
which many real improvements may be based. Thus, it must be 
regarded as an improvement to have the splint so constructed as that 
it may be readily lengthened or made shorter, to accommodate itself 
to the size of the patient ; or that the foot-piece should be furnished 
with a screw, for the purpose of making the extension more uniformly; 
or that the same mode of operating should apply also to the counter- 
extension. 

The adhesive plaster bands are, beyond all comparison, the best 
means of making permanent extension which are at present known to 
surgeons. Hitherto, one of the most serious difficulties in the way of 
extension, and the objection which has been most effectively urged 
against its adoption, has been the excoriations, ulcerations, and even 
sloughing, which so often occurred from the use of the various ex- 
tending bands about the ankle. This, together with the injuries oc- 
casionally inflicted by the perineal band, has been regarded by other 
surgeons than Dr. Mott, whose opinion we have already quoted, as a 
sufficient reason for preferring the flexed position. But no one who 
has employed the adhesive plaster extending bands will doubt that, 
so far as injuries to the foot and ankle are concerned, this objection is 
now entirely disposed of. It is adopted in many, perhaps most, of the 
American hospitals ; and while, the bands can generally be made to 
retain their places against an extension of twenty pounds or more, it 
is very seldom, indeed, that they occasion any inconvenience. I re- 
gard this simple invention, therefore, as one of the most important 
improvements in the treatment of fractures of the thigh, and it is not 
surprising that several claimants have appeared for the original sug- 
gestion. By Dr. Brinton it has been claimed for Dr. Ellerslie Wal- 
lace, of Philadelphia ; ] by Dr. Sargent for Dr. Gross, of the same city ; 2 

1 Note to first American edition of Erichsen's Surgery, p. 212. 

2 Note to 3d American edition of Miller's Practice of Surgery, p. 653. See also- 
N. Y. Med. Graz., vol. iv. p. 87. 



422 FRACTURES OF THE FEMUR. 

and by others for Dr. Swift, of Easton, Pa. ; l but, however this may 
be, to Dr. Josiah Crosby, of [New Hampshire ; is certainly due the 
credit of having brought it into notice. 2 

The mode of using adhesive plaster for extension is briefly as fol- 
lows : — 

A single band, long enough to extend from a point just below the 
knee to twelve or sixteen inches beyond the foot, and about three 
inches wide, is to be applied along each side of the leg. Instead of 
one band on each side, two may be employed ; which shall traverse 
each other somewhat obliquely, so that one band shall fall a little in 
front of the malleolus and one a little behind. Having wrapped the 
whole circumference of the ankle, including the malleoli and heel, in 
a heavy pledget of cotton, laid underneath the adhesive bands, a roller 
is now to be applied from the toes upwards as far as the knee, and 
secured with a little flour paste or starch. Each band should now 
be brought down below the bottom of the foot, and folded oyer a 
piece of board, the purpose of which board is to keep the bands 
asunder, so that they shall not press upon the malleoli. For an adult, 
the board may be three inches long by two and a quarter or two and 
a half inches wide, and three-eighths of an inch in thickness, perfo- 
rated in the centre for the passage of a stout cord. The cord being 
finally made fast to the foot- piece, the movable block, or to the weight, 
in case the latter is employed. 

The attempt to use the adhesive plaster also as a perineal band, for 
the purpose of making counter- extension, does not seem to have been 
equally successful, unless I except the experience of that very excellent 
surgeon, Dr. David Gilbert, of Philadelphia, and of one or two other 
gentlemen mentioned by him, whose practice I will presently describe 
more particularly. For my own part, I never could succeed to any 
purpose with these bands in the perineum, or at least no better than 
with the ordinary perineal bands ; and I very much fear that, notwith- 
standing the ingenious contrivances of my friend Dr. Gilbert, we have 
still to incur the risk of ulcerations, &c, from this portion of our 
dressings ; fortunately, however, the perineal band never completely 
ligates the limb, and it has rarely, therefore, been found so mischievous 
as the ordinary extending bands at the ankle. 3 In the fracture appa- 
ratus lately invented by the Burgeses, the peculiar mode of action of 
the perineal band, avoiding, as it does, pressure upon the front of the 
groin, diminishes still further this danger; and in the construction of 
my own splint, I have long had regard to the importance of this 
principle by attaching the anterior portion of the perineal band to an 
upright crutch-head, which is made to rise more or less from the top 
of the splint, according to the size or obesity of the patient. In 
B urges' and Lente's apparatus this principle is, however, most fully 
recognized, and the indication is most completely accomplished. 

1 North Amer. Med.-Chir. Rev., vol. iv. p. 584. 

2 See case reported in N. H. Journ. of Med., for 1851 ; also N. Y. Journ. of Med., 
vol. vi. 2d series, p. 137. See, also, Trans. Amer. Med. Assoc, vol. iii. p. 382. 

3 For cases of sloughing, &c, from perineal band, see N. Y. Journ. of Med., vol. xvi., 
2d ser., p. 261, March, 1856 ; also same journal, Jan. 1840, p. 239. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



423 



Dr. John H. Packard, of Philadelphia, calls attention to the value 
of India-rubber as a means of permanent extension, to be employed 
in connection with the adhesive straps. Dr. Buck recommends the 
same. 1 

Dr. Gilbert, as I have already stated, believes also that the adhesive 
plaster may be employed as successfully in making counter-extension 
as in extension. He published his first case of treatment by this 
method in the American Journal of the Medical Sciences for 1851, and 
since then he has used it in every case of fracture, not only of the 
thigh, but of the leg, as he affirms, with the happiest results. Drs. 
Kerr, Kenderdine, and Hunt, of Pennsylvania, who have also adopted 
Dr. Gilbert's method, speak of it in terms of commendation. In the 
first of the accompanying wood-cuts (Pig. 159) nothing is intended to 

Fig. 159. 




D. Gilbert's mode of making Counter-extension, and Extension. 

1. Anterior and posterior counter-extending adhesive bands, two and a half inches wide, crossing each 

other before they pass through the mortise holes. 2. The same crossing at the upper part of thigh and 

perineum. 3. Horizontal pelvic band, which maybe three inches wide. 4. Extending bands, receiving 

strap of tourniquet in the hollow of the foot. 5. Tourniquet. 

Fig. 160. 




Gilbert's Apparatus applied in a Case op Fracture of both Thighs. 
1, 1. Anterior adhesive counter-extending strips. 2. Distal extremity of posterior adhesive strip of 
left side. 3. Adhesive strip surrounding pelvis, binding the anterior and posterior strips to pelvis. 4. 
Inner extremity of the extending adhesive strip, forming stirrup under the foot, to receive the strap of 
the tourniquet. 5. Cicatrix of left thigh. 7, 7. Petit's tourniquet, by which the power was applied. 

be shown but the long splint and the adhesive straps employed in 
extension and counter-extension. It will be seen also that Dr. Gilbert 
employs the ordinary tourniquet of Petit for the purpose of making 
the extension. The "pelvic band" is a broad strip of adhesive plaster, 



1 Packard, Amer. Journ. Med. Sci., July, 1862. 



424 



FKACTUKES OF THE FEMUR. 



and serves to bind down the perineal bands more closely to the skin. 
If necessary, additional strips of adhesive plaster may be applied, and 
in order to increase their strength they may be doubled. 1 

H. L. Hodge, of Philadelphia, adopting the same measures of counter- 
extension, namely, the adhesive straps, has modified the idea of Gil- 
bert by securing the strips of plaster to the sides of the body instead 
of the perineum, and attaching them to an iron rod which is made to 
project from the top of the splint beyond the shoulder. 2 

Fig. 161. 




H. L Hodge's method of counter-extension in fracture of the femur. 

Lente, of Cold Spring, N. Y., has also occupied himself with the 
invention of an apparatus by which he hopes, in some measure at 
least, to obviate the usual inconveniences of the perineal band. The 
apparatus described by him possesses also many other peculiarities, 
and such as demand for it especial attention. I shall, therefore, per- 
mit him to explain to the reader its several parts in his own language. 
Speaking of the different forms of the straight splint, he remarks : — 

" The pressure of the counter-extending band upon the groin has 
always been the stumbling-block of this apparatus. Desault saw the 
advantage of making the tuberosity of the ischium the point cFappui, 
but failed, as we have seen, in his attempt to do so ; and various sur- 
geons have since contrived as many different plans for effectually 
carrying out his idea, but without complete success. No one, how- 
ever, has approached this nearer than the Burgeses. However, the fact 
seems to be that neither the groin nor the tuberosity is fitted to bear 
alone the pressure of the counter-extension in cases of considerable 
shortening, aud therefore of great tension in the application of the 
extending power. 

" It is therefore my object, in the further modification of the New 
York Hospital apparatus, to distribute the pressure on these two 
points ; and further, in order to render the pressure on the groin safer 
and more comfortable, and also to remove all pressure from the 
muscles, vessels, nerves, &c, of the thigh in front, I propose to add an 
iron brace (A, Fig. 162), extending, in a curved form, from the upper 

1 Gilbert, Amer. Journ. Med. Sci., April, 185 9, pp. 410-424. 

2 Hodge, Amer. Journ. Med. Sci., April, 1860. 



FRACTURES OF THE SHAFT OF THE FEMUR. 425 

end of the external splint directly across the body to the median line, 
and cushioned on its inner surface as represented in the engraving. 
Sliding on this, and furnished with a binding screw to fix it at any 
required point, is a plate, P, to the lower part of which is attached a 
buckle for securing the anterior extremity of the perineal band. By 
this arrangement, I am enabled to make the direction of the counter- 
extending force of this portion of the band correspond to the axis of 
the limb, instead of oblique ; and, furthermore, it allows me to dis- 
pense with all that portion of the outer splint between the crest of the 
ilium and the axilla ; thus reducing it to the original length of De- 
sault, obviating the constriction of the chest by the body-band, and 
producing a less irksome confinement of the upper part of the body. 
In lieu of the body-band, there is a pelvic strap extending from the 
end of the iron brace, to the movable plate of which it is secured by 
buckles, around the back to the top of the splint, thus binding the 
apparatus firmly to the pelvis, if found necessary. It should be men- 
tioned that the brace is so attached to the splint, through the ingenuity 
of Mr. Tiemann, surgical instrument maker, of New York, as to allow 
of its being shifted to either side, according as the fracture is on the 
right or left, or of being removed for packing. He has also made the 
long splint in two portions sliding on each other, so as to shorten or 
lengthen it according to the size of the patient, and to facilitate its 
package and transportation. Desault attached the posterior as well as 
the anterior extremity of the perineal band to the long splint ; but it 
will be found that, by so doing, he does not grasp with it, as he in- 
tended, the tuberosity ; on the contrary, when extension is applied, it 
slips under it or above it, and is thus almost totally ineffectual in 
relieving the groin. To be effective, it should be attached to the 
splint at a point considerably lower down ; and it is necessary that 
the medium of attachment should be movable, in order that, when 

Fig. 162. 




the upper end of the splint is placed opposite the christa ilii, it may be 
shifted, if necessary, a trifle upwards or downwards, that the band may 
exactly grasp the tuberosity. I therefore provide a button (B, Fig. 162), 
secured by a thumb-screw, and several holes at different contiguous 
points in the splint, to which it may be shifted with facility. The 
posterior end of the perineal band is either passed under the outer 
splint and buttoned, as shown at B, Fig. 162, or carried between the 
28 



426 



FRACTURES OF THE FEMUR. 



cushion and splint, over the top of the latter to the button, as indi- 
cated at E, Fig. 163. The latter arrangement is applicable especially 
to fat and muscular subjects, particularly females, who have an abun- 
dance of fat and other tissues covering the tuberosity, which might 
allow the band to slip by the bone unless attached in this manner. I 
propose, also, to attach both the extending and counter- extending 
bands to the apparatus through the medium of elastics. Upon sug- 
gesting this to Mr. Tiemann, I found that some one had anticipated 
me with regard to the extending band ; and Mr. T. has arranged a 
strong spiral spring in the ferule of the screw, which supplies the 
place of the elastic at that point. It is absolutely necessary that the 
elastics attached to the perineal band, which may be of India-rubber, 
should be very short, an inch or so, and very strong ; otherwise they 
will give too much to the extending force, and had better be dispensed 

Fig. 163. 




with entirely. These elastics are intended to fulfil two indications : 
first, to render the pressure more tolerable to the patient, as elastics 
always do ; secondly, to keep up an equable and uninterrupted trac- 
tion on the muscles of the thigh, thus tending still further to diminish 
the shortening, and to counteract the effect of any stretching or yield- 
ing in any part of the apparatus. In order to render the pressure ot 
the perineal band still less unpleasant, and less likely to cause excori- 
ation of the groin, it might be of service to apply several coatings of 
a mixture of collodion 25 parts, castor oil 1 part, which has been 



FKACTUKES OF THE SHAFT OF THE FEMUR. 427 

found to form in other parts of the body, and might form here, a 
smooth and enduring cuticle. 

" My remaining modification of the splint is a foot-piece (D, Fig. 
162), attached by a slide and thumb-screw to the mortise in the 
external splint, and capable of removal at pleasure. * * * In 
Fig. 163 this arrangement is dispensed with, and its place supplied 
by a foot-piece (C), which also obviates the necessity for the block for 
preserving the parallelism of the adhesive bands, since these bands 
pass from the leg, on either side, around this piece, binding firmly to 
the sole of the foot. The cords connecting it with the screw are so 
arranged as to draw uniformly on this, so as not to tilt it against the 
' ball' of the foot. By resting below the heel on the mattress, it serves 
to support the weight of the clothes, and also prevents eversion of the 
foot. This contrivance is in imitation of Boyer's, and may, by some 
surgeons, be preferred ; although it is, in my opinion, not so efficient 
as the foot-piece (D, Fig. 162). (F) is a wedge-shaped cushion, very 
useful in maintaining the whole apparatus in a level position, and 
taking off the pressure from the heel and tendo-Achillis. An inside 
splint, extending from the perineum to the inner malleolus, and a gut- 
tered splint for the upper and lower surfaces of the thigh respectively, 
with suitable cushions for the splints, complete this apparatus." 

Following the suggestion made by Dr. Neil, 1 who uses for this pur- 
pose a Spanish windlass, I have had the foot-block of my own splint 
(Fig. 161) so constructed as that counter-extension maybe made at the 
same moment with the extension. The principle is the same as that 
employed in the ancient "glossocomon," described by most of the early 
surgical writers. The advantages of this method are that the counter- 
extension, as well as the extension, can be made slowly, steadily, and 
firmly ; the patient cannot, if disposed to interfere with the dressings, 
loosen or disturb them ; the limb is acted upon equally in each direc- 
tion, and the rollers which secure the limb to the splint do not be- 
come drawn obliquely and disarranged by the daily attempts to 
increase or continue the extension. The only danger is, that, in the 
hands of inexperienced surgeons, too much force will be applied, and 
perineal ulcerations ensue. 

In constructing the perineal band, I now usually adopt the suggestion 
made to me some time since by Dr. Boardman, of Buffalo. A sheet 
of foolscap, or the half of a newspaper, is folded into a ribbon of about 
one inch and a half in width ; this is intended to give firmness to the 
perineal band, and to prevent its corrugation. The surface which is 
to be laid against the skin is then covered with cotton wadding, and 
the whole enveloped in a long, narrow strip of cotton cloth, and 
neatly stitched. The strip of cotton cloth must be much longer than 
the padded portion of the band, in order to tie through the fenestras. 
Before securing the band in place, a strip of patent lint should be 
laid in the perineum with its soft side against the skin. This may 
be occasionally renewed. 

With children I occasionally employ the simple splint shown in Fig. 

1 Philadelphia Med. Exam., vol. xi. p. 579. 



428 



FRACTURES OF THE FEMUR. 



165 ; yet if the little patient is restless and disposed to throw himself 
about the bed, I prefer, as I have before stated, the double splint shown 
in Fig. 166, to which is attached a screw of peculiar construction, called 
the " endless screw" (Figs. 167, 168, 169, 170), the pattern for which 



Fig. 164. 




SEItEJ^^CTT ] 



a 



The Author's Single Straight Thigh-Splint, for Children or Adults. — a. Crutch-head, with two 
rings for the passage of the perineal band, b, b. Upper sliding portion of the splint, c. Ratchet to secure 
the upper portion of the splint when drawn out. d, d. Lower sliding portion of the splint, to which is 
attached the foot-block, e. Foot-block, which, with the lower sliding portion of the splint, d, is moved 
upwards or downwards by the screw,/, g. Brass ring fastened to the outer end of the foot-block. The 
perineal band having passed through the rings in the crutch-head, is made fast to this ring; so that 
when the foot-block descends, extension and counter-extension are made at the same moment, h. Cross- 
piece, to steady the long splint. 

Fig. 165. 




The Author's Single Straight Thigh-Splint, for Children: or the straight splint in its simplest 
elementary form. 

Fig. 166. 




The Author's Double Straight Thigh-Splint, for Children or Adults.— Both of the long splints are 
laid outside of the two thighs. 



Fig. 167. 



Fig. 168. 



Fig. 169. 



Fig. 170. 



© © 





SCALE ONE-FOURTH OF FULL SIZE. 

Endless Screw, used by the Author >or making Extension in the Double Straight Splint.— Fig 

167. Front view. Fig. 168. Side view. Fig. 169. End view ; a is a screw working in a toothed wheel, 6. 

Fig. 170. Front removed, showing the plane part of toothed wheel for extension strap, c, c. Two small 

screws to fasten extension strap. 

was sent to me by some gentleman in Boston, whose name, I regret 
to say, I cannot now recall ; or, employing the same double splint, I 



FRACTURES OF THE SHAFT OF THE FEMUR. 



429 



make extension with the weight and pulley, and counter-extension 
with a perineal band. Indeed this has been my practice altogether of 
late. 

It will be found necessary, generally, to confine both limbs to the 
long side splints with rollers, over junks, the rollers being carefully 
applied from the foot to the groin, upon each limb. In addition to this, 
a broad band should be passed around the body and splints, over the 
pelvis. In this way alone can children be prevented from constantly 
disturbing the dressings. "When thus secured, these patients become 
completely manageable, and can be readily moved at any time from 
the bed to a lounge or even into the open air. 

In all cases one should prefer to use side splints, carefully fitted ; 
the whole, both side and long splints, being applied to the limb over 
neatly-made cotton pads or junks, of which there ought to be laid 
upon every part of the leg and thigh as many as may be necessary to 
prevent unequal pressure. 

I am especially careful to place a thick but soft pad underneath the 
knee, since if this is not done the forced extension into which the 
hamstrings are thrown soon becomes irksome and even painful. A 
thick compress ought also to be placed under the back of the leg, 
just above the heel, to prevent the weight of the limb from producing 
ulceration. 

To this general plan of treatment now recommended for fractures 
of the femur the writer makes no exceptions, unless it be in the case 
of a fracture of the neck of the femur 
occurring in very old persons, or in frac- 
tures just above the condyles, where the 
direction of the fracture is obliquely 
downwards and forwards; in the former 
of which often no rule can be adopted, 
except that the patient should be placed 
in that position which may be found 
most comfortable; and in the latter of 
which the flexed position seems indeed 
the most rational, yet, according to the 
evidence furnished by Malgaigne, its 
advantages over the straight position are 
far from being established. In fractures 
occurring just below the trochanter 
minor, my own experience agrees with 
that of the distinguished author just 
quoted, that the straight position is still 
the best ; an experience which seems to 
me also to admit of a satisfactory ex- 
planation. It is not directly upwards, 
but rather outwards and upwards, that 
the lower end of the proximal fragment 
is thrown by the action of the psoas 
magnus and iliacus internus, so that in order to meet the supposed 
indication it will be necessary to carry the lower part of the limb 



Fig. 171. 




430 FRACTURES OF THE FEMUR. 

outwards also, a position which would certainly be found very incon- 
venient, if not actually impracticable, in the majority of cases. 

Nor can the tendency of the upper fragment to rise, and consequently 
to separate from the lower, be effectually met by posture alone, unless 
the thigh is completely flexed upon the body; a position, again, which 
will be found inconvenient, if not impossible. 

It is apparent, therefore, that by posture alone we can only very 
imperfectly accomplish an approximation of the fragments ; while, in 
adopting the flexed position, we have almost entirely, whatever may 
be said to the contrary, deprived ourselves of the means of extension 
and counter-extension. On the other hand, admitting that by the 
straight position we have momentarily provoked a resistance which 
flexion of the limb might have prevented, we shall be able, slowly 
but effectually, to overcome this resistance by steady and continued 
extension. In the one case we have made a present gain, but a final 
loss ; and in the other a present loss results in our final gain. So it is 
that experience has shown in more than one case which has come 
under our observation, that although for a few moments, or perhaps 
for several hours, after the straight position has been assumed in these 
fractures, the upper fragment will rise spasmodically, yet, after a time, 
longer or shorter, and especially after the application of the side 
splints and bandages, this tendency will cease altogether. 

My convictions upon this subject are clear, but since they do not 
correspond with the convictions of a pretty large proportion of prac- 
tical surgeons, I am compelled to regard the question of posture in 
this particular fracture as still open. I will take the liberty to sug- 
gest, however, that it is by the results of carefully recorded experience 
alone that it can be ever determined, and not by any reference to 
physiological or anatomical arguments, which I suspect have had 
hitherto much more influence with surgeons in respect to this ques- 
tion than personal observation. 

In hospitals, and in private practice whenever the circumstances of 
the patient will warrant the expense, a bed constructed with especial 
view to fractures of the thigh ought to be regarded as an essential 
part of the apparatus; always contributing to the comfort of the 
patient, if it is not absolutely necessary to the attainment of the most 
complete success. Indeed, where some form of fracture-bed cannot be 
procured, and the patient is compelled to lie upon a common cot bed- 
stead, or a common post bedstead, or upon the floor, I cannot think 
the surgeon ought to be held in any degree responsible for the result. 

The fracture-beds in use among American surgeons are exceedingly 
various, among which I will mention, as being especially ingenious, 
the beds invented by Jenks, Daniels, the Burgeses, Addinell Hewson, 
of Philadelphia, 1 J. Rhea Barton, B. H. Coates, of the same city, 2 and 
J. Crosby, of Manchester, N. H. 3 

Of these several contrivances, Jenks' bed (Fig. 172) has been for the 

1 Hewson, Amer. Journ. Med. Sci., July, 1858, p. 101. 

2 Eclectic Repertory, 5th and 9th vols. 

3 Crosby, Treatise on Milit. Surg., by Frank- H. Hamilton, 1865, p. 413. 



FEACTUEES OF THE SHAFT OF THE FEMUE. 



431 



longest period in use among American surgeons, and its excellencies 
most thoroughly tested. It is composed of " two upright posts about six 
feet high, supported each by a pedestal; of two horizontal bars at the 
top, somewhat longer than a common bedstead ; of a windlass of the 



Fig. 172. 




Jenks' fracture-bed. From Gibson. 



same length placed six inches below the upper bar; of a cog-wheel 
and handle; of linen belts, from six to twelve inches wide; of straps 
secured at one end to the windlass, and at the other having hooks 
attached to corresponding eyes in the linen belts; of a head-piece 
made of netting ; of a piece of sheet-iron twelve inches long, and hol- 
lowed out to fit and surround the thigh ; of a bed-pan, box and cushion 
to support it, and of some other minor parts. 

" The patient lying on this mattress, and his limb surrounded by the 
apparatus of Desault, Hagedorn, or any other that may be preferred, 
the surgeon, or any common attendant, will only find it requisite to 
pass the linen belts beneath his body [attaching them to the hooks on 
the ends of the straps, and adjusting the whole at the proper distance 
and length, so as to balance the body exactly], and raise it from the 
mattress by turning the handle of the windlass. While the patient is 
thus suspended, the bed can be made up, and the faeces and urine evacu- 
ated. To lower the patient again, and replace him on the mattress, 
the windlass must be reversed. The linen belts may then be removed, 
and the body brought in contact with the sheets." 1 

But in my own experience no bed has proved so complete and uni- 
versally applicable as the fracture-bed invented more recently by 
Daniels ; and which may be used either as a double inclined plane or 

1 Gibson's Surgery, vol. i. p. 320. 



432 



FRACTURES OF THE FEMUR. 



as a single "horizontal plane suitable for the support of the patient 
when his limb is dressed with the straight splint. 

Sometimes I have had constructed a simple frame, covered with a 
stout canvas sacking, having a hole at a point corresponding with the 
position of the nates, and this I have laid directly upon a common four- 




E. Daniels' Fracture-Bed. 

post bedstead. A mattress and one or two quilts must be placed upon 
the boards of the bedstead underneath the sacking, and a sheet or two 
above the sacking, upon which last the patient is to be laid. In ar- 
ranging the linen underneath the patient, the most convenient plan is, 
instead of using only one sheet, which will require that a hole shall 
be made in it corresponding to the hole in the sacking, to employ two 
sheets, and, doubling them separately, to bring the folded margin of 
each from above and from below to the centre of the opening. When 
the patient has occasion to use the bed-pan it is only necessary that 
two or four persons should lift this frame, and place under each corner 
a block about one foot in height, or it may be raised by a pulley and 
ropes suspended from the ceiling. 

The "invalid bed," to which I have already alluded as a "fracture" 
bed, invented by Dr. Josiah Crosby, of Manchester, N. H., and which 
was introduced into many of the XL S. general hospitals by order of 
the Surgeon-General, has been found to be of great service, not only 
in the management of invalids, in the general sense of that term, but 
also in the treatment of gunshot fractures of the thigh. Indeed, I 
have had occasion to use this bedstead in Bellevue Hospital, and I 
can say that its value in many cases can scarcely be over-estimated. 

We may also floor over a common bedstead, having previously, in 
case it is an adult whom we have to treat, removed the foot-board, so 
that we may extend the floor two or three feet beyond the usual length 
of the bedstead. In the centre of this floor we may make an opening, 
so arranged as to be closed by a board, slid underneath, or by a door 



FRACTURES OF THE SHAFT OF THE FEMUR, 
Fig. 174. 



433 




Fig. 175. 




E. Daniels' Fractore-Bed. 
"A (Fig. 173) represents a platform of suitable length and width, supported by four legs, a. To the 
upper surface of the platform is attached a cross-piece, 5, at a short distance from the centre, and 
directly through the centre of the platform is made a circular hole, c (in dotted lines), said hole 
having a semicircular cut or recess in the cross-piece b. To the straight edge of the cross-piece b 
there is attached, by hinges, d, a board, B, termed the body plane, the width of which may corre- 
spond with that of the platform A, and when depressed its outer edge maybe even with the edge of 
the platform. The sides of the body plane may be elevated, or raised so as to be slightly concave on its 
outer surface. To the opposite side or edge of the cross-piece b, and at each side of the semicircular cut 
or recess formed by the aperture c, there are attached by hinges, e, cast-iron plates, ft, which are 
provided with grooves or ways at their sides, in or between which plates D D work. The plates 
C 0, D D (one on each side) are thigh plates, and their edges are provided with projections,/, in which 
a shaft, g, works, one on each plate ft On each shaft g there is placed a pinion, which gears into 
a rack attached to the under surface of the plates D D. At one end of the shafts g are attached i-atchets, 
g', in which pawls, J, catch, said pawls being attached to the sides of the plates ft To the 
outer edges of the plates D D are attached by hinges, 1c, boards, E E; these boards are leg planes, 
and are slightly raised at their inner ends, where they are connected to the plates D, in order to form 
depressions to correspond to the shape of the legs. To the under surface of each leg plane there is 
attached a metal guide, I, in which a rack, m, works ; the outer ends of the racks have bars, n, projecting 
from them at right angles. To each leg plane is attached a shaft, o, having a pinion, p, and ratchet, 
q, thereon, and pawls, r, which catch into the ratchets q, the pawls being attached to the outer sides of 
the leg planes. The pinions gear into the racks m. The body plane, and also the thigh and leg planes, 



434 FRACTURES OF THE FEMUR. 

are covered by a suitable mattress, E, with a bole made through it to correspond with the hole in the 
platform A, and the mattress is slit or cut to cover properly the thigh and leg planes without interfering 
■with their movements. To the under side of the platform is attached by hinges a flap, F, having a 
stuffed pad or cushion, t, upon it, which, when the flap is secured upwards against the platform, fits in 
the hole in the platform and mattress. The flap is secured against the platform by a button, w." 

fastened with, a couple of leathern hinges, and closed by a spring 
catch. 

A very comfortable bed, especially for children, can sometimes be 
made from a cot. But it will be necessary always to nail a piece of 
board firmly across the top and bottom of the bedstead when the sack- 
ing is at its utmost tension, in order to prevent the side rails from 
falling together. The top board must be nailed on vertically, like 
an ordinary head-board, so as to prevent the pillows from falling off, 
but the bottom piece should be at least one foot wide, and laid hori- 
zontally to support and steady the apparatus as it extends beyond the 
oot. 

Having had occasion to assist the late Dr. Treat in the management 
of a fracture of the thigh, in the case of a little girl not quite three 
years old, I was struck with the simplicity and completeness of an 
arrangement which he had made to prevent the bed and the dressings 
from becoming soiled with the urine. It was only to leave directly 
underneath the nates a complete opening through to the floor for the 
escape of the urine, and to protect the margins of the sacking and 
sheets, which came nearly together at the opening, with pieces of oiled 
cloth folded upon themselves. It was found that not only the bed 
was in this way kept dry, but the dressings also ; it being now ob- 
served that the dressings had become wet heretofore by soaking up 
the moisture from the bed rather than by the direct fall of the urine 
upon them. 

Having prepared the bed for the reception of the patient, we may 
proceed as follows, in the case of a simple fracture. 

Lay the perineal band in its place, and four pieces of bandage trans- 
versely where the broken thigh is to repose ; over the four transverse 
bands lay a firm splint, long enough to reach from the tuberosity of 
the ischium to the lower margin of the popliteal space, and nearly as 
wide as the diameter of the thigh. This may be made of a board 
covered with cotton cloth, and carefully stuffed, so as to fit all the 
inequalities of the several portions of the limb. It can be fitted with 
sufficient accuracy by comparing and trying it upon the sound limb. 
Of all the side splints this is the most important, and the greatest care 
ought to be exercised in its construction. 

The patient, having been previously stripped and washed with 
warm water and soap, is laid upon the bed with his thigh reposing 
upon the back splint ; the head and trunk being at first moderately 
raised to prevent any strain upon the muscles of the front of the thigh. 
An assistant seizes the knee firmly with both hands and makes 
moderate traction so as to steady the limb, and at the same time pre- 
vent the fragments from penetrating the flesh; while the surgoon lays 
his long strips of adhesive plaster upon each side of the leg in the 



FRACTURES OF THE SHAFT OF THE FEMUR. 435 

manner which has already been described, protecting the ankles with 
small pads made of cotton batting. Elevating the foot a little more, 
he proceeds to apply a roller from the toes up to the hamV Every- 
thing is now ready for the long splint, which, in case only one is used, 
is laid outside the broken limb, and the perineal band adjusted and 
tied temporarily in a bow knot; one long junk is pressed between 
the splint and the limb, reaching from the hip to the heel, and imme- 
diately the surgeon fastens the extending bands to the foot-piece or 
to the extending screw, and tightens it moderately so that the assistant 
may release his hold upon the knee. 

The whole limb is now steadied and at rest, and the patient seldom 
fails to declare himself relieved ; after which, the surgeon may pro- 
ceed more at leisure to complete his dressings. 

A padded splint should next be laid upon the inside of the thigh, 
extending from the groin to immediately below the knee, but it must 
not be allowed to press much upon the knee, as it would be likely to 
become painful, and perhaps vesicate the skin over the projecting 
bones. Another splint in front, extending from the groin to within 
one inch of the knee, completes the inclosure of the limb ; and the 
whole are to be retained in place by tying the four transverse bands, 
previously laid under the limb, around the three short lateral splints, 
and the long outside splint. In some cases I prefer to secure the short 
lateral splints to the limb independently of the long splint, and then 
it is necessary to lay a fourth short splint upon the outside of the 
limb, between it and the long splint, otherwise the transverse bands 
will cut into the flesh. 

The perineal band ought now to be made permanently fast, and the 
extension carried to the point of utmost tolerance on the part of the 
patient, while the surgeon proceeds to apply a roller from the instep 
to the groin, enveloping at the same time the splint and the limb in 
its successive turns ; but as he progresses upwards, he should lay be- 
tween the limb and the splint and underneath the limb as many soft, 
cotton pads as may be needed to fill up all the inequalities ; these 
pads it will be found necessary to extend from the malleolus externus 
to near the middle of the leg, and to lay them under the tendo- Achillis 
and knee, outside of the knee, above the trochanter major, &c. 

Before the surgeon leaves he should ascertain whether the extension 
is too violent, or whether it is quite painful, and in either case it must 
be a little slackened. 

If the patient is a child, or an intractable adult, the double splint 
ought to be preferred, and the unbroken limb be secured to the 
opposite long splint in the same manner as the broken, only that no 
perineal band or extending straps are needed for the sound limb. 

The rules which have now been laid down in relation to the order 
and manner of dressing, are the results of my own personal experi- 
ence as to what method is generally the most convenient and useful ; 
but circumstances must occasionally require that they should be some- 
what varied or modified ; and when other forms of apparatus are em- 
ployed than those for which I have already indicated my preference, 
the rules of procedure must be determined by the peculiarities of the 



436 FRACTURES OF THE FEMUR. 

apparatus. In short, much must always be left to the discretion of the 
surgeon, only that he never can be at liberty to dress a broken thigh 
in a hasty or slovenly manner. 

During the first two or three weeks the limb ought to be seen daily, 
and at each visit a careful examination of every portion of the ap- 
parel should be made, so far as this can be done without opening or 
removing the dressings ; and whenever anything is disarranged, or has 
become too tight or too loose, so far as may be necessary to correct 
these faults, the bandages should be removed and readjusted. Gene- 
rally they can be tightened by over-stitching or by additional band- 
ages. If the patient complains of pain at any point where a splint 
presses, his complaints should receive prompt attention, arid the cause 
should be ascertained and removed, if possible. Especially ought the 
surgeon to look to the condition of the perineum ; and generally no 
harm comes of slackening or removing the band whenever this part 
is to be inspected, since the weight of the body alone is sufficient, 
during the few minutes it is to be removed, to prevent any shortening 
of the limb. 

During the first week the extension should be increased, according 
to the ability of the patient to endure it, each day, and after that, 
steadily maintained until union has taken place. 

In the case of an adult, we ought never to encourage a hope that he 
can be released. from his splints in less than eight weeks, although we 
may find it safe to remove them as early as the end of the sixth week; 
but the patient seldom wears the splints too long, while they are often 
removed too soon. Eemember that the fragments are in nine cases 
out of ten uniting side by side and not end to end ; the muscles which 
act upon them are powerful, and the weight of the limb is great, so 
that the time within which the limb can be safely trusted alone is 
never short. 

The extension may, however, be relaxed as soon, generally, as the 
twenty-eighth day, and the leg may be lifted daily after this, and the 
knee and ankle very gently flexed and rubbed, but never so early as 
this period can the short side splints be abandoned safely. Still more 
important do I regard the continuance of the long side splint — no 
longer now as a means of extension, but only of retention — lest the 
weight of the limb should turn the foot gradually out, or occasion 
some other deformity. 

It is true that in some cases, where patients are remarkably careful 
and everything has gone along well, I have, at the end of four weeks, 
applied a paste bandage from the toes to the groin, and permitted 
them to get up upon crutches; but I would not dare to recommend 
this practice to the inexperienced surgeon or to the incautious patient. 
It has often done well, but sometimes it has proved disastrous. It is 
an extra hazard which the surgeon should be reluctant to incur. 

When at length the patient is permitted to leave his bed, a pair of 
crutches become indispensable, and during the following two months 
but little weight should be borne upon the limb ; and in rising from 
the bed care must be taken lest the limb should be so situated as that 
its weight would make it bend. 



FKACTUKES OF THE CONDYLES. 



437 




Dr. Crosby's specimen of 
fracture of the external con- 
dyle. 



§ 5. Fractures of the Condyles. 
(a.) Fractures of the External Condyle. 

Dr. Alph B. Crosby/ of New Hampshire, has published an account 
of a case of simple fracture of the external condyle, in a young man 
twenty-one years of age, and which happened from a sudden twist of 
the limb, while he was undressing himself to 
bathe. He was "standing on a shelving bank, Fi g- !76. 

with the right leg flexed over the left in order to 
remove his pantaloons : he lost his balance, par- 
tially twisted the leg, and fell to the ground." 
Six months after, the fragment was removed by 
Dr. Crosby, through an incision below the con- 
dyle. The recovery of the young man has been 
complete. 

The accompanying drawing represents the 
specimen as seen from its lower or cartilaginous 
surface, and of its actual size. 

Dr. T. S. Kirkbride has also reported an ex- 
ample of simple fracture of this condyle, which 
was produced by the kick of a horse, the blow 
having been received upon the inside of the knee. 
"When this patient entered the Pennsylvania Hospital, Dec. 1834, the 
knee was much swollen, and crepitus was plainly felt, but the frag- 
ment was not displaced; the muscles upon the 
outer side, however, were so strongly contracted 
as to abduct the leg, and produce considerable 
angular deformity. The limb could be easily 
made straight, but it returned to its former 
position of abduction as soon as it was released. 
When fully extended, slight bending of the 
joint did not give severe pain; but when in any 
degree flexed, all motion was very painful. 

The limb was placed in a long straight frac- 
ture box, and cold applications were made; 
great swelling followed. It was kept extended 
in this manner, or in the long splint of De- 
sault, twenty-eight days ; at which time union 
seemed to have taken place, but the motions at 
the joint were very limited, and productive of 
great pain. From this period the limb was 
laid in a splint, so constructed as that the angle 
at the knee could be changed daily. At the 
end of about six weeks he began to walk on 
crutches, and he could then flex the leg to a 
right angle. 2 

Sir Astley has related a case of compound fracture of the same 




Sir Astley Cooper's case of 
fracture of the external con. 
dyie. 



1 Crosby, New Hampshire Jourri. of Med., 1857. 

2 Kirkbride, Auier. Journ. Med. Sci., May, lb35 



vol. xvi. 



p. 32. 



438 FEACTURES OF THE FEMUR. 

condyle, produced by falling from a curb-stone upon the knees. The 
man died on the twenty-fourth day. On examination after death, the 
external condyle was found to be broken off] and also a considerable 
fragment was detached from the shaft higher up. 1 

(b.) Fractures of the Internal Condyle. 

Dr. Thomas Wells, of Columbia, S. C, has reported an example of 
fracture of the internal condyle, accompanied with a dislocation of the 
head of the tibia outwards and backwards. The man was about forty 
years old, and intemperate. Dr. Wells was not called until two days 
after the injury was received, when he found the limb greatly swollen 
and gangrenous. The man's account of himself was that while walk- 
ing in the back yard he fell, and thus dislocated his knee, and that 
he was then brought into the house, being unable to stand upon his 
feet. It does not appear that any attempt was made to reduce the 
limb, probably because his general condition indicated that speedy 
death was inevitable. On the fourth day he died. The autopsy dis- 
closed, in addition to the dislocation of the tibia, that a thick scale of 
bone was broken from the inner part of the inner condyle, but it 
remained attached to the ligaments. 2 

A case reported to me by Dr. Lewis Riggs, a very intelligent sur- 
geon, practising in Homer, Oneida Co., N. Y., was more successful. 

A lad, set. 15, was kicked by a horse, the blow being received upon 
the right knee. Dr. Riggs saw him within three hours after the acci- 
dent, and found the internal condyle of the right femur broken off, 
carrying away more than half the articulating surface of the joint ; 
the tibia and fibula were at the same time dislocated inwards and 
upwards, carrying with them the broken condyle and the patella. The 
displacement upwards was about two inches, and the sharp point of 
the inner fragment had nearly penetrated the skin. There was no 
external wound. The knee presented a very extraordinary appear- 
ance, and the lad was suffering greatly. Being at a distance from 
town, and the doctor having no chloroform or pulleys with him, he 
was obliged to depend solely upon the aid of five men who were pre- 
sent. The first attempt at reduction was unsuccessful, but in the 
second attempt, when the men were nearly exhausted in their efforts 
at extension and counter-extension, and while the doctor was pressing 
forcibly with both hands upon the two condyles, the bones suddenly 
came into position, except that the breadth of the knee seemed to be 
slightly greater than the other, a circumstance which was probably 
due to the irregularities of the broken surfaces, which prevented per- 
fect coaptation. 

Neither splints nor bandages were required to maintain the bones 
in place ; but anticipating the probable occurrence of anchylosis, and 
with a view to making the limb as useful as possible in this condition, 
the doctor placed him upon "a double inclined plane," which being 

1 Sir Astlej Cooper, On Disloc, &c, op. cit.. p. 239. 

2 Wells, Amer. Journ. Med. Soi., May, 1832, vol. x. p. 25. 



FKACTUKES OF THE CONDYLES. 439 

supplied with lateral supports, would also prevent any deflection in 
either direction, in case the limb was disposed to such displacement. 

The subsequent treatment consisted in the use of cold water dress- 
ings. Very little inflammation followed. A portion of the integu- 
ment sloughed, but the bone was not exposed, and it healed rapidly. 
On the twenty-fourth day Dr. Riggs gave to the joint passive motion, 
and this was repeated at intervals until, at the end of three months, 
he was able to walk with a cane. At the end of a year Dr. Riggs 
examined the leg, and found the knee a very little larger than the 
other, and he could not flex it quite as completely. In all other 
respects it was perfect, and the boy himself declared it was as good as 
the other. 

Treatment of Fractures of either Condyle. — The few cases of these acci- 
dents which have been reported have been, with one or two exceptions, 
treated in the straight position. In Kirkbride's case any degree of 
flexion was painful, although there was little or no displacement of the 
fragment; and we think we can see, in the relative position of the arti- 
cular surfaces of the tibia and femur, a sufficient reason why the straight 
or nearly straight position must generally be preferred. Whichever 
condyle is broken, the remaining condyle will be sufficient to prevent 
a dislocation and consequent shortening of the limb, unless, indeed, 
the dislocation has already occurred as an immediate consequence of 
the injury. It is very certain that it would not take place from the 
action of the muscles when the limb was straight. In the flexed posi- 
tion I can conceive that it might take place, but yet not easily. It is 
not a dislocation of the limb, then, that we seek chiefly to avoid, but 
a deflection of the leg to the right or to the left, according as one or 
the other of the condyles has been broken. It will be readily seen 
that, in order to resist this tendencj^, nothing but the straight position 
will answer, and that for this purpose it will be necessary to lay a 
long splint upon one or both sides of the limb, and to secure the 
whole length of both thigh and leg to this splint. The long fracture 
box used by Kirkbride, if well cushioned on all sides, seems to me at 
once to answer most completely this important indication, rendering 
it even unnecessary to employ a bandage, since the opposite sides of 
the box will compel the limb to adopt the proper position. 

As to the remainder of the treatment, it must consist essentially in 
the active employment of such means as are calculated to prevent and 
allay inflammation ; especially ought the surgeon not to omit to avail 
himself of so valuable an antiphlogistic agent as cool water lotions. 

As soon as the union is consummated the joint surfaces should be 
submitted to passive motion in order to prevent anchylosis ; and it 
would be better to commence this so early as to hazard somewhat a 
displacement of the fragment than to wait too long. It may not, in 
some cases, be improper as early as the fourteenth day, and in nearly 
all cases it should be practised as early as the twenty-eighth. 



440 . FRACTURES OF THE FEMUR. 



(c.) Fractures between the Condyles and across the Base. 

Etiology. — A fracture of this character may be produced by a blow 
received upon the side of the limb or upon the lower extremity of the 
femur; sometimes the blow has been received directly upon the patella 
when the knee was bent, and Bichat mentions a case in which it was 
produced by a fall upon the feet. 

Symptoms. — This fracture is easily distinguished from the preceding 
by the much greater mobility of the fragments and by the palpable 
shortening of the limb, since an overlapping of the broken end is 
here almost inevitable. Each fragment may be felt to move separately, 
and the motion will be accompanied with crepitus. 

Prognosis. — The danger of violent inflammation in the joint is im- 
minent, and anchylosis of the knee is to be anticipated as the most 
favorable result, since the joint surfaces are likely to be rendered im- 
movable by fibrinous deposits in their immediate vicinity, and also 
by the adhesion of the muscles to one another and to the bone higher 
up, where the fracture of the shaft has occurred. More fortunate 
results than these may, indeed, be hoped for, inasmuch as they have 
occasionally been noticed, but they cannot fairly be expected. 

In a majority of cases, such accidents have demanded, either imme- 
diately or at a later period, amputation. If recovery takes place, a 
shortening of the thigh is inevitable. Mr. Canton, of London, has 
twice performed successfully resection of the joint end of the bone in 
such accidents. 1 

Treatment. — Malgaigne saw a patient who had been treated by 
Guerbois with the aid of extension and counter-extension, who was 
confined to his bed five months, and who had at the end of eight years 
very little motion in the joint, and he seems disposed to charge in 
some measure these unfortunate consequences to the position in which 
the limb was placed, namely, the straight position. But, in my opinion, 
it is much more reasonable to suppose that, if the treatment was at 
all responsible for the results, the error consisted in too long and un- 
necessary confinement, and in too much extension. I suspect that 
the mere matter of position had nothing to do with the anchylosis. 
Malgaigne does not, however, himself recommend anything more than 
a very slight amount of flexion at the knee ; and to this practice I 
am prepared to give my assent; since it will give to the limb the best 
position in case anchylosis does occur, and it is not inconsistent with 
the employment of the moderate amount of extension which alone is 
justifiable after this accident. If the young surgeon should differ 
with me in opinion as to the necessity or propriety of using great 
force to retain the fragments in place and prevent overlapping, I beg 
him to consider that this accident never happens except from the 
application of an extraordinary force, and that consequently intense 
inflammation and swelling are almost certain to ensue ; and that in 
some cases, the very fact that immediately after the accident, or for 
some hours succeeding, no swelling occurs, or muscular contraction, 

1 Lancet, Aug. 28. 1858. Trans. London Path. Soc, 1860. 



FRACTURES OF THE CONDYLES. 441 

and that replacement of the fragments is easily accomplished, is evi- 
dence only of the great severity of the injury, and that the whole 
system is lying under the shock : to which, if the patient does not 
succumb, sooner or later reaction will ensue, and the fragments will 
be gradually drawn up with a resistless power. The surgeon ought 
to remember also that to make extension in this case, he is obliged 
to pull upon those very ligaments and tendons about the joint which, 
having been torn or bruised, must soon become exquisitely sensitive. 

The long straight box, already recommended when speaking of 
fracture of one condyle, is equally applicable here ; only that it needs 
a foot-board, or some sort of foot-piece to which an extending appa- 
ratus may be secured, and that a pillow should be placed under the 
knee to give the limb the proper flexion. 

Case. — A man was admitted into St. Thomas's Hospital, London, 
Sept. 17, 1816, with a fracture between the condyles, accompanied also 
with a fracture through the shaft higher up, occasioned by being 
caught in the wheels of a carriage while in motion. There was a 
small wound opposite the point of fracture, and the external condyle 
was displaced outwards. 

The limb was laid in a fracture box, and in a position of semi- 
flexion. 

On the 18th of November, the external condyle, having protruded 
through the skin, and being dead, was removed with the forceps, 
bringing with it a portion of the articular surface. 

On the 6th of December he was discharged from the hospital, and 
in February following he was walking without any support, and with 
the free use of the joint. 1 

Case. — A gentleman living about eighty miles from town was 
thrown from his carriage, breaking the left femur just above the con- 
dyles into many fragments, so that when I saw him, on the following 
clay, the attending physician showed me about four or five inches of 
the entire thickness of the shaft which he had removed. The external 
condyle was completely separated from the internal, and was quite 
movable. 

In this case the attempt to save the limb resulted in the loss of the 
patient's life on the sixth or seventh day. 

Separation of the Lower Epiphysis. — M. Coural relates the case of 
a boy 11 years old, who, while his leg was buried in a hole up to his 
knee, fell forwards, separating the lower epiphysis from the shaft, and 
at the same time driving the shaft behind the condyles into the popli- 
teal space. The epiphysis also became tilted in such a manner that 
its lower extremity was directed forwards. The limb was amputated. 

Madame Lachapelle mentions a case in which traction at the foot of 
a child in the act of birth caused at the same time a separation of the 
low r er epiphysis of the femur and the upper epiphysis of the tibia. 
The child was born dead. 2 

Dr. Little presented to the New York Pathological Society, May 24, 

1 A. Cooper on Disloc, &c, op. cit., p. 239. 

2 Malgaigne, op. cit., t. i. p. 69. 

29 



412 FEACTUEES OF THE PATELLA. 

1865, a specimen obtained from his own practice. A boy, set. 11, 
while hanging on to the back of a wagon, had his right leg caught 
between the spokes of the wheel while it was in rapid motion. A few 
hours after the accident, Dr. Little found the upper fragment of the 
femur projecting through an opening in the upper and outer part of 
the popliteal space. On examination, the wound did not appear to 
communicate with the knee-joint. Under the influence of an anaes- 
thetic the fragments were reduced ; the reduction occasioning a dull 
cartilaginous crepitus. There was at the time no pulsation in the 
posterior tibial artery, and the limb was cold. The limb was laid 
over a double inclined plane. The following day the upper fragment 
w^as again displaced, and it was found that it could only be kept in 
place by extreme flexion of the leg. This position was therefore 
adopted and maintained ; considerable traumatic fever followed, with 
swelling, and on the thirteenth day a secondary hemorrhage occurred 
from the anterior tibial artery near its origin, and it became necessary 
to amputate. The boy made a good recovery. The specimen showed 
that the line of separation had not followed the cartilage throughout, 
but had at one point traversed the bony structure. 

Dr. Yoss at the same meeting remarked that he had met with the 
same accident. There was no protrusion of bone, but an abscess 
formed, and it became necessary to amputate. 

Dr. Buck saw a case which occurred in the practice of Dr. Hugh 
Walsh, of Fordham. The subject was a boy 14 years old, and it hap- 
pened in the same manner as with Dr. Little's patient. 1 I know of 
no other cases of this accident. 



CHAPTEE XXIX. 

FEACTUEES OF THE PATELLA. 

Causes.— Of twenty-one fractures of the patella which have come 
under my observation, twenty were the result of direct blows or of 
falls upon the knee. In the remaining example the fracture was due 
solely to muscular action; a sailor, aged about thirty years, had 
caught the heel of his boot in a knot-hole in the floor, which threw 
him backwards, and in the effort to sustain himself the patella was 
broken transversely. Dr. Kirkbride has reported a case in which both 
patellae were broken in a similar manner, but at different periods. The 
patient was a girl, set. 29, who was admitted into the Pennsylvania Hos- 
pital, Oct. 16, 1833. "In falling backwards, and making an effort to 
save herself," the right patella had been fractured. She was dismissed 
cured on the 2d of December, and on the 20th of April following she 
was readmitted, with a fracture of the left patella, produced in the 

1 Little, Voss, Buck. N. Y. Journ. Med., Nov. 1865. 



FRACTUKES OF THE PATELLA. 



443 



same manner as before; but in her effort to save the right limb, the 
left received all the strain, and the patella gave way. 1 Dr. Kirkbride 
records another instance of fracture from muscular exertion in a man 
set. 32, who attempted to jump into a cart, by raising his body with 
his hands resting upon the bottom of the vehicle ;* and Dr. Hayward, 
of Boston, saw a case in the Massachusetts General Hospital, in a man 
set. 67, which occurred in consequence of a false step in descending 
a flight of stairs. 2 

Pathology. — All the fractures produced by muscular action have 
been found to be transverse, and the same is true generally of fractures 



Fig. 178. 





produced by direct blows; occasionally, however, we meet with lon- 
gitudinal fractures, or with fractures more or less oblique and com- 
minuted. Seventeen of the fractures seen by me were simple and 
transverse, one was simple and oblique, and one was comminuted. 
The oblique fracture was in the person of a child five years old, who 
fell on his left knee, Jan. 31, 1848, breaking off a small fragment from 
the upper and inner margin of the patella. It did not separate from 
the main fragment except when the knee was flexed, and it was then 
thrown directly forwards, presenting to the finger a sharp point. Dr. 
Flint, who was with myself in attendance, kept the leg extended, and 
had the knee constantly moistened with cool lotions. Six months 



Fk. 180 




after, I could not discover any traces of the accident. There is a 
specimen, illustrating a similar fracture, but not united, in the collec- 



1 Kirkbride, Amer. Journ. Med. Sci., Aug. 1835, vol. xvi. p. 330. 

2 Hayward, Am. Journ. Med. Sci., vol. xxx., from New Etig. Quart. Journ., July, 

1842. 



444 FBACTUKES OF THE PATELLA. 

tion at St. Thomas's Hospital, London. 1 Dupuytren, A. Cooper, and 
others, have also mentioned cases of longitudinal fracture. 

I have seen a double transverse fracture, or a fracture of both 
patellae, in a man set. 22, who fell from a third-story window, striking, 
he says, upon his knees. He was taken to the Hospital of the Sisters 
of Charity, in Buffalo, and, after a few weeks, made an excellent 
recovery. 

Symptoms. — The symptoms which characterize a transverse fracture 
of the patella are sufficiently diagnostic. The fragments are separated 
from each other, the superior fragment being drawn upwards more or 
less, according to the power and activity of the muscles, or the degree 
to which the ligamentous covering of the patella has been torn. In 

some cases, also, the violent flexion of the 
F jg- 181 - knee has completed the separation which, 

otherwise might have been only partial. 
By passing the finger along the anterior 
surface of the limb with a moderate de- 
gree of firmness, the depression between 
the fragments will be made manifest. 

No crepitus can be expected unless the 
fragments remain in contact, a condition 
which is very unusual. The patient is 
unable to stand, and especially is the power 
of extending the leg upon the thigh com- 

th!klT tS SeparatGd by fleXi ° Q ° f P letel y lost - Usually a good deal of swell- 
ing immediately succeeds the accident, and 
after a time the skin becomes more or less discolored from effusions of 
blood. If the fracture is longitudinal or oblique, a slight separation 
is usually present, but not always very easily detected. 

Prognosis. — One of my patients, who had a comminuted fracture, 
with other serious injuries, died, but not as a consequence of the frac- 
ture. In the following case the fragments appear never to have united, 
although the patient recovered : — 

John Sharkie, set. 24, a soldier in the British service, while serving 
in the East Indies, was struck on the right knee while he was in a 
sitting posture, with his leg bent under him. 

He was immediately placed under the charge of the surgeon of the 
89th regiment of infantry. During the first eleven days no splints or 
bandages were applied, on account of the severe inflammation and 
swelling. A compress was then placed over both fragments, and 
they were bound together by rollers, &c. The whole limb was sus- 
pended on an inclined plane, the foot being made fast to a foot-board. 
This treatment was continued four months. When the bandages were 
removed, the limb was badly swollen, and immediately the upper frag- 
ment was drawn up toward the body. Eighteen months elapsed be- 
fore he could walk, even with the aid of a cane. 

March 27, 1855, twenty-nine years after the injury was received, he 

1 A. Cooper, On DhIoc, &c, op. cit., p. 232. 




FRACTURES OF THE PATELLA. 



445 



Fig. 182. 




was an inmate of the Buffalo Hospital, and I was permitted to ex- 
amine his knee carefully. 

The lower fragment is not displaced, but when the leg is straight 
upon the thigh the upper fragment lies 
two and a half inches from the lower, 
and when it is flexed upon the thigh the 
npper fragment is removed five inches 
from the lower. 

There is no ligament or other bond of 
union, so far as I can discover. He walks 
with very little or no halt, but he cannot 
walk fast. 

In every other instance which has 
come under my notice union has taken 
place at periods varying from twenty- 
four to fifty-eight days, the average being 
thirty-eight days. Fifteen cases have 
united by a ligament varying in length 
from one-quarter to one-half an inch. 
These measurements, made upon the 

living subject, may not be mathematically accurate, but they cannot 
be far from the truth. 

In the case of a man set. 40, the ligamentous union, at first complete, 
seems to have subsequently given way in part. He called upon me 
for advice nine weeks after the fracture had occurred. The patella 
was surrounded with bony callus, so that it was considerably wider 
than the other. The fragments appeared to be united by a short liga- 
ment, except on the inner side, where there was a separation or 
rupture of the ligament to the extent of one-quarter of an inch. The 
patient explained this by saying that the splint was removed at the 
end of four weeks, and that after a week more he began to walk, but 
that he almost immediately felt it tear or give way on the inner side. 

During the autumn of 1865 I examined the leg of Dr. B., a graduate 
of Bellevue Medical College, and found a transverse fracture of the 
right patella, with great displacement of the upper fragment. He in- 
formed me that he had fallen six years before, when nineteen years 
old, upon a stone, striking upon the patella. The fracture was recog- 
nized, and the limb was laid upon a straight splint. At the end of 
three months the limb was removed from the splint, and the union was 
found to be complete, with a separation of the fragments to the extent 
of half or three-quarters of an inch. The knee was much anchylosed. 
Soon after this the upper fragment began to draw up, and at the end of 
a year was as much displaced as it is now. At this moment it is dis- 
placed three inches, and seems to be held to the lower fragment only 
by a narrow ligament attached to their inner margins. He extends 
and flexes the leg perfectly, and walks without the least halt, but this 
limb wearies sooner than the other. 

February 16, 1866, John Donahue, set. 50, was admitted into my 
wards at Bellevue, with a refracture of the right patella. He stated 
that it was first broken eight weeks before, and that it had united, but 



446 FEACTUEES OF THE PATELLA. 

that the day before his admission, while seated on the ground, he 
attempted to rise, and that the ligament suddenly gave. I found the 
fragments separated one inch, and by pressing the upper fragment 
against the lower a slight crepitus was occasioned. His limb was 
placed upon a single inclined plane, and union soon occurred. 

Dr. Kirkbride has reported a case of ligamentous union of the 
patella, in which the ligament was two and a half inches long, and 
was attached only to the inner margins of the fracture. " He was able 
to walk as rapidly as ever, and without perceptible limping." 1 A 
similar case is reported by Dr. Watson, of New York, in which the 
fragments became separated three and a half inches. 2 In both instances 
the fragments were supposed to have united by a short ligament, 
which had become lengthened by premature use of the limb ; in the 
case reported by Kirkbride, the ligament seemed to have partly torn, 
as in the case reported by myself. Dr. Coale presented to the Boston 
Society for Medical Improvement, at its April meeting in 1856, a 
specimen of a fractured patella taken from a man sixty -five years old, 
the fracture having occurred ten years before. The fragments were at 
first so closely united that no division between them could be dis- 
covered, but subsequently they became separated at their outer edges 
one inch, and at their inner edges one-eighth of an inch. 3 

Twice, I believe, I have seen a bony union of the patella. The first 
instance is that to which I have already referred as an oblique or 
longitudinal. fracture across one corner of the patella; and in the other 
example the action of the muscles upon the upper fragment was pre- 
vented by the occurrence of a fracture of the shaft of the femur at the 
same time, which permitted the thigh to shorten upon itself. The 
man was about twenty-five years old, and in a fall from a scaffold had 
broken his left femur, and also the patella. The patella was broken 
transversely near its middle, and also longitudinally near its inner 
margin. The fragments were all distinctly made out. Drs. Lewis and 
Dayton, of Buffalo, were in attendance, and on the fifth day I was 
called in consultation. We dressed the limb with a long straight 
splint, employing moderate extension and counter-extension. The 
patella was covered with strips of adhesive plaster. On the fifty- 
eighth day I found the fragments of the patella united. June 3, 1854, 
five months after the accident, I examined the limb carefully. The 
femur was shortened half an inch, and, although the two main frag- 
ments of the patella were separated half an inch, the bond of union 
seemed to be bone. It was hard, and allowed of no motion in the 
upper fragment separate from the lower. The lateral fragment was 
also apparently united by bone and in place. He had but little motion 
in the knee-joint, yet he walked very well, and was able to pursue his 
trade, as a carpenter, without much inconvenience. 

Sir Astley Cooper succeeded in obtaining a bony union in some 
longitudinal fractures, but in a majority of cases it failed, owing to the 

1 Kirkbride, Amer. Journ. of Med. Sciences, vol. xvi. p. 32. 

2 Watson, N. Y. Journ. of Med. and Surgery, vol. iii., first series, p. 306. 

3 Coale, Boston Med. and Surg. Journal, vol. liv. p. 402. 



FRACTURES OF THE PATELLA. 447 

want of apposition in the fragments. It might seem that it would be 
easy to accomplish apposition in all longitudinal fractures, but expe- 
rience has shown that it is not always, the fragments being kept 
asunder partly by the action of the oblique fibres of the vasti and 
partly by the pressure of the condyles of the femur, especially when 
the leg is slightly flexed. 

Whether the fracture is transverse or longitudinal, a bony union 
may occasionally be obtained when the fragments are retained in 
absolute contact for a sufficient length of time; but the failure to 
procure a bony union is not a matter of consequence, since a short 
ligament is equally useful. 

Post, of New York, has reported three cases of compound fracture 
of the patella extending into the knee-joint ; brought to a successful 
termination. 1 

In a case mentioned by Eve, of Augusta, occasioned by the kick 
of a horse, and in which amputation became necessary on the tenth 
day, "the knee-joint was found filled with dark grumous blood; a 
portion of the cartilage of the internal condyle of the os femoris was 
chipped off, and the patella broken into a number of fragments." 2 

Lewitt, of Michigan, has related a case of fracture in a lad set. 16, 
produced by striking his knee against a piece of timber, which re- 
sulted in suppuration of the knee-joint, but from which he finally 
recovered with the perfect use of the limb. The fracture of the patella 
was oblique, traversing only its upper and outer margin, and it was 
never much displaced. 3 

Dr. Levergood, of Pennsylvania, has reported a similar case, in which 
it became necessary to open the joint freely, yet it was followed by 
an excellent recovery, only a slight anchylosis remaining at the knee- 
joint. 4 

Treatment. — The dressing which I have usually employed in the 
treatment of this fracture consists of a single inclined plane, of suffi- 
cient length to support the thigh and leg, and about six inches wider 
than the limb at the knee. This plane rises from a horizontal floor 
of the same length and breadth, and is supported at its distal end by 
an upright piece of board, which serves both to lift the plane and to 
support and steady the foot. The distal end of the inclined plane 
may be elevated from six to eighteen inches, according to the length of 
the limb and other circumstances. Upon either side, about four inches 
below the knee, is cut a deep notch. The foot-piece stands at right 
angles with the inclined plane, and not at right angles with the hori- 
zontal floor ; it may be perforated with holes for the passage of tapes 
or bandages to secure the foot. 

Having covered the apparatus with a thick and soft cushion care- 
fully adapted to all the irregularities of the thigh and leg, especial 
care being taken to fill completely the space under the knee, the 

1 Post, New York Journ. of Med., vol. ii., first series, p. 367. 

2 Eve, Southern Med. and Surg. Journ., 1848 ; also Bost. Med. Journ., vol. xxxvii. 
p. 427. 3 Lewitt, Medical Independent, Sept. 1856. 

4 Levergood, Amer. Journ. Med. Sci., Jan. 1860. 



us 



FRACTURES OF THE PATELLA 



whole limb is now laid upon it, and the foot gently secured to the 
foot-board, between which and the foot another cushion is placed. 

The body of the patient should also be flexed upon the thigh, so as 
the more effectually to relax the quadriceps femoris muscle. 

Fig. 183. 




The Author's Mode of Dressing a Fractured Patella. ■ 
a. Bed. b. Floor of apparatus, e. Foot-piece, furnished with fenestras through which straps may he 
passed to secure the foot, and with pins on each margin, d. Single inclined plane fastened to the foot- 
piece at any height, by means of a hook dropped over the pins, e, e. Cushion ; thicker under the knee 
than at either end. /. Roller to secure leg and thigh to the inclined plane ; not completely applied, g. 
Adhesive plasters laid over a compress and crossed under the splint. Those from ahove'pass through a 
notch in the splint below the knee, h, h. Ends of the compresses, seen from under the adhesive plasters. 

A compress made of folded cotton cloth, wide enough to cover the 
whole breadth of the knee, and long enough to extend from a point 
four inches above the patella to the tuberosity of the tibia, and one- 
quarter of an inch thick, is now placed on the front of, and above the 
knee. While an assistant presses down the upper fragment of the 
patella, the surgeon proceeds to secure it in place with bands of 
adhesive plaster. Each band should be two or two and a half inches 
wide, and sufficiently long to inclose the limb and splint obliquely. 
The centre of the first band is laid upon the compress partly above and 
partly upon the upper fragment, and its extremities are brought down 
so as to pass through the two notches on the side of the splint and 
close upon each other underneath. The second band, imbricating the 
first, descends a little lower upon the patella, and is secured below in 
the same manner. The third, and so on successively until the whole 
extent of the compress and knee is covered, is carried more nearly 
at right angles around the leg and splint; the last bands passing 
obliquely from below the ligamentum patellae upwards and backwards. 
The dressing is now completed by passing a cotton roller around the 
whole length of the limb and splint, commencing at the toes and 
ending at the groin. This is to be applied lightly, as its object is only 
to support and steady the limb upon the splint. 

The great advantage which this mode of dressing possesses is, that 
it does not ligate the leg or thigh completely, since, on either side, 
between the broad margins of the splint and the points where the 



FKACTURES OF THE PATELLA. 449 

straps and bandages touch the limb, there is a space, more or less con- 
siderable, against which no pressure is made, and through which the 
circulation may go on without impediment ; so that, however firmly 
the bands are drawn across the knee, no swelling occurs in the foot. 
As to its efficiency, the best testimony which can be presented is the 
simple fact that of six cases treated by this method, four have united 
by a ligament of only one-quarter of an inch in length, and two by a 
ligament of half an inch. 

The following example of a fracture of both patellsG will illustrate 
the general advantages of this dressing: — 

John Dundas, set. 22, fell, October 22, 1852, in the night, while 
asleep, from a window in the third story of a dwelling-house, striking 
with his knees upon the stone side- walk. 

On the tenth day I took charge of him at the Buffalo Hospital of 
the Sisters of Charity. I found both limbs in Gibson's modification 
of Hagedorn's splint for fractured thighs, with a figure-of-8 bandage 
loosely applied. The fragments were very much displaced. I im- 
mediately proceeded to inclose each leg, from the toes upwards as far 
as the knee, with a paste bandage, and then having properly cush- 
ioned the limbs and laid them over two separate inclined planes, I 
secured the fragments in place with adhesive plaster ; subsequently 
the limbs and planes were made fast together by successive turns of 
a roller. 

The knees were examined frequently, and the dressings occasion- 
ally renewed. 

November 28, 1852, thirty-seven days after the fractures had oc- 
curred, the splints and bandages were finally removed. Both patellae 
had united by ligamentous tissue, the length of which was about one- 
quarter of an inch. 

In a few weeks more he left the hospital, walking with only a slight 
impairment of the motions of the joints. 

The plan adopted by M. Gama, of Yal de Grace, 1 is similar to that 
which I have now described, but the splint upon which the limb 
reposes is not so wide, while width is an essential point in the attain- 
ment of the objects which I propose. Dr. Weill, of Philadelphia, uses 
also the adhesive plaster straps, but they are not placed outside of the 
splint. 2 Such, also, I understand to be Mr. Alcock's method of using 
the adhesive plaster. 3 

The dressing and apparatus employed by Wood, of King's College 
Hospital, is very similar to my own, but, as will be seen by the accom- 
panying drawing, the splint is only five or six inches wide. Dr. Wood 
has substituted hooks for the notches. 4 

Dr. Dorsey, of Philadelphia, employed a very simple apparatus, 
which will serve to illustrate the general plan adopted by many sur- 
geons, both at home and abroad. It is liable, however, to the objec- 
tion already stated, namely, that it interrupts too much the circula- 

1 Malgaigne, Traite des Fractures, etc. op. cit., p. 764. 

2 Philada. Med. Examiner, vol. x. p. 1. 

3 Practical Observations on Fractures of the Patella and of the Olecranon, by 
Thomas Alcock, p. 29(3. i Fergusson's Surgery, p. 307. 



450 



FEACTURES OF THE PATELLA. 



tion of the limb. His apparatus consists of a piece of wood half an 
inch thick and two or three inches wide, and long enough to extend 

Fig. 184. 




Wood's apparatus. 



from the buttock to the heel ; near the middle of this splint, and six 
inches apart, two bands of strong doubled muslin, a yard long, are 
nailed. The splint is then cushioned, and the limb laid upon it, a 

Fig. 185. 




John Syng Dorsey's patella splint. 



roller being first applied from the ankle to the groin, encompassing 
the knee in the form of the figure-of-8 ; after which the two muslin 
bands are secured across the knee in such a manner as that the lower 
one shall draw down the upper fragment, and the upper one elevate 
the lower fragment. 

A single instance will explain the danger of ligation to which I 
have alluded, and which, although it may be greater in case a starch 
or dextrine bandage is used, exists in some degree, whatever material 
for bandaging is employed, if it is applied to the whole circumference 
of the limb, and constant attention is not paid to the progress of the 
swelling. 

"A vine-dresser, aet. 40, of a good constitution, fell and received a 
simple transverse fracture of the patella on the 15th of January. The 
medical officer called upon to attend him applied first a bandage for 
the purpose of drawing together the fragments, and afterwards a 
starched bandage extending from the toes to the upper part of the 
thigh; the limb was then put upon an inclined plane. The patient 
was visited a few times, but, as he scarcely suffered, the apparatus 
was in no way disturbed. On the first of March (sixteenth day) the 



FKACTUKES OF THE PATELLA. 



451 



attendant returned to remove the bandage, when the odor arising from 
the limb led him to believe that gangrene had taken place, and Dr. 
Defer was sent for. Dr. Defer found the limb in the following state : 
The toes, which were not covered by the bandage, were completely 
insensible and mummified. The bandage being removed, the gan- 
grene was perceived to extend within seven inches of the knee, and 
was arrested in its progress. The foot was cold, and was totally in- 
sensible; the epidermis was raised up, and was beginning to be sepa- 
rated from the skin. The articulation of the ankle was exposed, and 
the ligaments destroyed. The bones of the leg were also exposed in 
their lower third, and the tendons were in a sloughy state. Amputa- 
tion was performed, and the patient recovered." 1 

Very little better than the starch bandage, and exposing the patient 
in a still greater degree to the dangers of ligation and strangulation, 
are either of the methods recommended by Sir Astley Cooper, Figs. 
186, 187. 

Fig. 186. 




Sir A. Cooper's method by circular tapes. 

Fig. 187. 




Sir A. Cooper's method by a leather counter-strap. 

Mr. Lonsdale's instrument, Fig. 188, is ingenious, but complicated. 
It is also liable to the serious objection that it forbids almost entirely 
the use of bandages, which, while they are capable of doing great mis- 
chief when they bind the limb too closely, are capable also of proving 
eminently serviceable when they press upon certain portions of the 
limb, and not with too much force. 

Malgaigne's hooks or clamps I regard as liable to more serious 
objections, and, notwithstanding considerable testimony in their favor, 
I should be reluctant to recommend them. 

In case the fracture is oblique or longitudinal, it will only be neces- 
sary to lay the limb in a straight position, so as to prevent that lateral 

1 Anier. Journ. Med. Sci., vol. xxiv. p. 462, from Gazette Medicate, No. 28. 



452 



FKACTURES OF THE PATELLA. 



displacement of the fragments which has been shown to occur when 
the limb is flexed. It will not be necessary to employ a splint, unless 

Fig. 188. 




Lonsdale's Apparatus for Fractured Patella. — A. B. Two vertical iron bars, each supporting a 
horizontal one ; these horizontal ai-ms slide upon the vertical bars, but can be secured at any point by 
the screws C D. To the horizontal beams are attached other vertical rods, which are movable, and yet 
fixable by screws, as at E. Finally, to each of these last upright pieces is fixed an iron plate, F F, by 
means of a hinge-joint, which keeps the patella in place. The foot-piece is movable up and down upon 
the main body of the apparatus, and can be made fast at any point, so as to adapt the splint to limbs of 
different lengths. 

the patient is unmanageable and demands restraint, nor to elevate the 
foot. After the swelling has subsided, a slight amount of lateral 
pressure, accomplished by a few turns of a roller, with or without 
compresses, as the circumstances may seem to demand, will complete 
the mechanical part of the treatment. 

I have not mentioned the rapid and sometimes intense inflammation 
to which the knee-joint is liable after a fracture of the patella ; and 
which is often greatly aggravated by the injudicious application of 
bandages. In no instance ought the bandages to be applied very 
tightly at the first dressing, and during the first five or six days the 
patient ought to be seen once or twice daily, and the most prompt 
attention given to any complaints of pain or soreness about the knee. 
From the beginning, cloths moistened in cool water should be con- 
stantly laid over the dressing ; but in case adhesive plaster is used, 
we must be careful not to soak the straps sufficiently to loosen them. 

If the swelling and inflammation increase rapidly, it would be far 
better to remove the straps or bandages altogether for a few days, 
than to take the risks consequent upon their continuance. 

The anchylosis which usually follows the recovery of the patient, 
and which is often almost complete, is to be overcome by long-con- 
tinued passive motion ; but great care must be taken not to rupture 
the ligament, as we have already seen happen in some cases. 

Dr. Alfred C. Post, of the New York Hospital, has excised the 
knee-joint in a case of anchylosis of long standing ; the limb being 
so much flexed in consequence of a comminuted fracture of the patella, 
as to be not merely useless, but an intolerable encumbrance. The 
patient was a laboring man of about forty years of age. This opera- 
tion was made in preference to amputation, at the request of the man 
himself. 1 



' Post, New York Med. Gazette, vol. i. p. 309, Nov. 1850. 



FRACTURES OF THE TIBIA. 



453 



CHAPTEE XXX. 



FRACTURES OF THE TIBIA, 



Fig. 189. 



Development of the Tibia. — The tibia is formed, usually, from three 
centres of ossification ; one for the shaft and one for either extremity. 
Ossification commences in the shaft at about the fifth 
week of foetal life. In the upper epiphysis it appears 
at birth, and unites with the shaft at about the twenty- 
fifth year. Generally it forms the tubercle, but occa- 
sionally the tubercle has a distinct point of ossification. 
The lower epiphysis commences to ossify during the 
second year, and unites with the shaft at about the 
twentieth year. The malleolus internus is occasionally 
formed from an independent centre. 

Etiology of Fractures of the Tibia. — Fractures of the 
tibia alone are, in a large majority of cases, produced 
by direct blows, such as the kick of a horse, or a blow 
from a stick of wood ; in one instance I have seen it 
broken by a kick from a Dutchman's boot. It is occa- 
sionally broken by a fall upon the foot, the force of 
the impulse being expended before the fibula gives 
way, but almost always the fibula breaks at the same 
moment, or immediately after the fracture has taken 
place in the tibia. 

Dr. Proudfoot, of New York, has reported an exam- 
ple of fracture of the tibia in utero, produced in the 
sixth month of pregnancy, by violent pressure upon 
the abdomen. 1 

Pathology, Division, &e. — In an analysis of twenty- 
seven fractures of the tibia, not including fractures of 
the malleoli, six were found to have occurred in the 
upper third, eleven in the middle third, and eight in the lower third. 
Six of the twenty-seven are known to have been transverse, or only 
slightly oblique. It is probable, also, that several of the remainder 
were transverse. In this respect, therefore, fractures of the tibia alone 
will be found to differ materially from fractures of the tibia and fibula; 
but it is only in accordance with the general observation that indirect 
blows produce almost constantly oblique fractures, and direct blows 
somewhat more frequently transverse. 

Many examples of fractures of the tibia extending into the knee- 
joint are recorded by surgeons, most of which were compound, or 
otherwise seriously complicated, so as to render amputation necessary, 




Development of 
the tibia. (From 
Gray.) 



1 Proudfoot, Bost. Med. and Surg. Journ., vol. xxxv. p. 2S8, 1846; from New York 
Journ. Med. 



454 FRACTURES OF THE TIBIA. 

and the consideration of which scarcely belongs properly to a treatise 
upon fractures. 

The malleolus internus is broken frequently at the same time that 
the ankle-joint is dislocated, and this accident will be considered in 
that connection. 

Separation of Epiphyses. — "We have already mentioned (p. 441), that 
Madame Lachapelle has reported a case of separation of the upper 
epiphysis of the tibia, and of the lower epiphysis of the femur, occa- 
sioned by pulling at the foot during birth. 

Dr. Yoss, of New York, has seen a separation of the lower epiphy- 
sis in a boy 14 years old, who in falling had caught his foot between 
two blocks of wood. The upper fragment protruded through the 
skin. Reduction was effected, but subsequently a portion of the 
epiphysis became necrosed and was removed. He finally recovered 
with a useful joint. 1 

Prognosis. — No shortening can occur in this fracture unless one or 
both ends of the fibula are displaced, a complication which I have 
noticed in two instances, but in neither case did the shortening exceed 
one-quarter of an inch; unless, indeed, the fracture occurs above the 
fibula, or the fibula bends and remains bent, or the comminution and 
direction of the fracture is such at either end as to allow the femur 
or the astragalus to become impacted. I have never recognized either 
of these conditions. 

Occasionally the upper fragment has been slightly displaced for- 
wards. With these exceptions, and one other of delayed union which 
I shall presently mention, this bone, in my experience, has been found 
to unite promptly and without any appreciable deformity. Other 
surgeons have noticed occasionally that the upper end of the lower 
fragment has become displaced toward the fibula. Dr. Donne, of 
Louisville, has reported an example of delayed union in a simple 
transverse fracture of the upper end of the tibia. The man was in- 
temperate. Ten weeks after the accident no union had occurred, and 
Dr. Donne introduced a seton, and in about six weeks the fragments 
were firm. 2 

If the fracture extends into either the knee or ankle-joint, the danger 
of anchylosis is imminent, yet experience has shown that it may some- 
times be avoided. 

When the malleolus is broken off, it generally becomes slightly 
displaced downwards, and in this position a complete bony or liga- 
mentous union takes place. 

Treatment. — The tendency to displacement, in a fracture of the tibia, 
is usually so slight, if it exists at all, that simple dressings, light 
splints of felt or binder's board, with rest in the horizontal posture 
upon a pillow, fulfil nearly all the indications which are present. The 
following cases will illustrate the usual course of these accidents. 

Mrs. W., of Buffalo, fell, Oct. 19, 1848, striking on her right knee, 
breaking the tibia transversely just below the tuberosity. 

1 Voss, N. Y. Journ. Med., Nov. 1865, p. 133. 

2 Donne, Amer. Journ. Med. Sci., vol. xxviii. p. 524 ; from Western Journ. Med. 
and Surg., Aug. Ib41. 



FRACTURES OF THE TIBIA. 455 

The fall was the result of a misstep on level ground, and was at- 
tended with only slight bruising of the soft parts. She says that on 
attempting to rise she discovered what had happened, the bone pro- 
jecting very distinctly, and she pushed and pulled it into place with 
her own hands. 

I dressed the limb by laying it upon a pillow, outside of which 
were placed two broad deal splints, tying the whole snugly together 
with several strips of bandage. At a later period the leg and thigh 
were laid over a double inclined plane. 

At the end of six weeks all dressings were removed, and the frag- 
ments were found to have united firmly, and so perfectly as that the 
point of fracture could not be traced. 

Peter Hamil, of Buffalo, set. 29, was admitted into the hospital Aug. 
31, 1849, with an injury to his left leg, which had occurred two days 
before. A young surgeon had examined the limb, and thought the 
femur was broken just above the joint. He had applied a roller from 
the toes to the thigh ; and to the thigh were applied lateral splints. 
These dressings were on the limb at the time of his admission, and 
were not removed until the next day. I could not then discover any 
fracture or displacement, and the dressings were discontinued, the 
limb being merely laid upon pillows. 

Oct. 4, when examining the limb, I detected a slipping sensation, 
like that produced in a false joint, through the upper end of the tibia, 
and I now easily understood what had been mistaken for a fracture of 
the femur. It was a transverse fracture through the upper end of the 
tibia, and without displacement. 

No splints were afterwards applied, and on the 25th of November, 
three months after admission, he was dismissed, the motion between 
the fragments having ceased, but the knee still remaining quite stiff. 

The presence of inflammation, with other complications, may, how- 
ever, occasionally render the treatment more difficult and the results 
less satisfactory. 

John Mahan, set. 39, admitted to the Buffalo Hospital, Feb. 16, 
1853, with a compound fracture of the right tibia, near the middle of 
the leg. The bone was broken by the kick of a Dutchman. I found 
the limb much swollen and very painful, and I laid it carefully over a 
double inclined plane, and directed cold water irrigations; I also 
directed morphine in full doses. The inflammation for several days 
threatened the complete loss of his limb. On the tenth day the distal 
end of the upper fragment was projecting in front of the lower, and I 
depressed the angle of the splint and made moderate pressure upon the 
upper fragment. On the twentieth day the fragments were bent back- 
wards, and I placed a compress behind. On the thirty- seventh day 
we took the limb from the inclined plane, and trusted alone to side 
splints. On the forty-fifth day we removed all dressings. The frag- 
ments had not united. The limb was then laid upon a pillow, and six 
days later a firm gutta-percha splint was applied for the purpose of 
steadying the bone, but the splint was removed daily in order that the 
leg might be bathed and rubbed. He was allowed to sit up. On the 
fifty-ninth day motion could still be perceived between the fragments, 



456 FRACTURES OF THE TIBIA. 

and he was directed to use crutches. On the ninety-third day the 
union was found to be firm, the upper fragment remaining slightly 
displaced forwards. 

In case the fracture extends into the knee-joint, it is best to lay the 
limb upon pillows or in a nicely-cushioned box, and nearly straight. 
'No extension or counter-extension is necessary here any more than 
in other fractures of the tibia alone, nor are lateral splints or rollers 
necessary or proper at first, as a general rule; but especial attention 
should constantly be given to the prevention of inflammation, and of 
subsequent anchylosis. The omission to employ splints in a case of 
this kind was charged against a surgeon in Vermont as evidence of 
malpractice. I am happy to say, however, that, in this particular case, 
he was sustained by the testimony of the medical men and by the 
verdict of the jury; but the attempt which the reporter has made to 
defend this as a universal practice in fractures of the leg, or of the 
tibia alone, is unfortunate, and evinces a lack of practical experience. 1 

Whatever position is adopted, and whatever means of support or 
retention are employed, if bandages and splints are applied tightly or 
injudiciously, great suffering and irreparable mischief to the knee-joint 
may be the consequence. 

A man, set. 23, entered the Pennsylvania Hospital, July 18, 1839, 
with an oblique fracture through the head of the tibia. A physician 
had applied a bandage and splint to the leg, and sent him twenty miles 
to the city, and, on examination after his arrival, the whole limb as 
high as the groin was much swollen, red, and excessively painful. 
The knee-joint was distended and very tender. All dressings were 
immediately removed, and the limb laid in a long fracture-box slightly 
elevated at the foot ; cool lotions were applied, and the patient was 
freely bled, both from the arm and by the application of leeches. The 
limb was kept in this position about six weeks, and at the end of two 
or three weeks more he was dismissed, cured. Dr. Norris, who was 
the hospital surgeon in attendance, has, in his report of the case, very 
properly taken this occasion to warn surgeons of the danger of exces- 
sive bandaging and splinting in this kind of fracture, as well as in all 
other fractures of the lower extremities. 2 

Fractures of the malleolus, unaccompanied with any other accident, 
demand only that the limb should be laid upon its outer or fibular 
side, with the foot so supported as that it shall incline inwards towards 
the tibia. In this simple disposition of the limb we have done all that 
can be done by any mechanical contrivance toward approaching the 
lower fragment to the shaft from which it has been broken. 

1 Boston Med. Journ., vol. liv. p. 1, March, 1856. 

2 Norris, Amer. Journ. of Med. Sci., vol. xxiii. p. 291. 



FRACTURES OF THE FIBULA. 457 



CHAPTEE XXXI. 

FRACTURES OF THE FIBULA. 

Development of the Fibula. — The fibula is formed from three centres 
of ossification — one for the shaft, and one for each extremity. Bone 
begins to be deposited in the shaft at about the sixth 
week of foetal life, in the lower extremity during the Fig. 190. 
second year, and in the upper extremity during the fourth 
year. The lower epiphysis unites with the shaft about 
the twentieth year, and the upper about the twenty-fifth 
year. 

I have not found any recorded examples of separation 
of these epiphyses. 

Causes of Fracture. — In a record of thirty-two cases I 
have been able to ascertain the cause satisfactorily in 
eighteen, of which number three were the results of falls 
directly upon the bottom of the foot, but which were 
probably accompanied with a twist of the foot, four of a 
slip of the foot in walking on level ground, or on ground 
only slightly irregular, and twelve of direct blows. 

Pathology. — In all of the fractures which have been 1 

produced by falls upon the' bottom of the foot, and in all 
except one produced by a slip of the foot, the accident 
was accompanied with a dislocation of the ankle ; the 
foot being turned outwards. In the one exceptional case 
mentioned, the dislocation may also have occurred, but 
the fact is not known. 

Both Malgaigne and Dupuytren have noticed a dis- 
location in the opposite direction, or a turning of the 
foot inwards, more often than a turning outwards. I Fibu^a^^om 
cannot think their observations were carefully made. Gray,) 

Moreover, in at least seven of the twelve fractures pro- 
duced by direct blows the tibia has been thrown more or less inwards, 
and consequently the foot has turned out. 

In twenty-four examples the fracture of the fibula has taken place 
within from two to five inches of the lower end of the bone. Twice I 
have found the external malleolus broken off, and seven times the 
internal malleolus. 

Four of the fractures occurring in consequence of direct blows were 
compound, and one was also comminuted. 

Prognosis. — In a majority of cases, where the fibula has been broken 

from two to five inches above the lower end, the fragments have united 

inclined toward or resting against the tibia ; occasionally I have seen 

them displaced backwards. Once the fibula refused to unite altogether. 

30 



458 



FRACTURES OF THE FIBULA 



Fig. 191. 




Fracture of fibula 
near lower end. 



The malleoli have generally -united nearly or quite in place, but in 
two instances the external malleolus has been found displaced very 
much downwards. 

Of the compound fractures, two required amputation, one was treated 
by resection of the lower end of the tibia, and one 
died without any operation. Douglas has reported 
a case of compound dislocation with fracture of the 
fibula, which being reduced, he was able to save the 
limb, but not without much difficulty, and the ankle 
remained stiff. 1 Other surgeons have met with simi- 
lar success, but I shall refer to this subject again 
under the head of compound dislocations. 

Of those which recovered, twenty-eight in number, 
ten have been found to have more or less unnatural 
prominence of the internal malleolus, and in two of 
these the malleolus, or lower end of the tibia, projects 
very much. In nearly all of these examples the foot 
appears somewhat inclined outwards. 

Generally the ankle-joint has remained stiff for 
some time after the bandages have been removed ; 
and probably in all cases in which the accident was 
accompanied with a dislocation of the tibia. But 
this stiffness has usually disappeared after a few 
weeks or months. Twice I have noticed considerable 
stiffness after about six months; three times after one year; in one 
case after two years ; and in one case after twenty years the ankle 
would occasionally swell, and become quite stiff. In one case it re- 
mained almost immovable after twenty years ; and in a still more 
remarkable instance, I examined the limb thirty years after the acci- 
dent, when the man was sixty-three years old, and although there 
existed no swelling or deformity, yet this leg was not as muscular 
as the other, and he declared that up to this time the ankle remained 
quite tender to the touch, and that occasionally it became painful. 

"When I come to speak of dislocation of the ankle, I shall adopt 
the usual nomenclature, and shall name all those dislocations in which 
the tibia projects inwards from the foot, " inward dislocations of the 
tibia ;" yet I have some doubts as to the propriety of this appellation. 
This accident seems to me to have been in general rather a lateral 
rotation of the foot, or of the astragalus, upon the lower articulating 
surfaces of the tibia and fibula. Of all the ginglymoid joints, the 
ankle approaches most nearly in form to a ball and socket joint, in 
consequence especially of the marked prolongations of the malleolus 
internus and externus. In other ginglymoid articulations lateral dis- 
placements are not unfrequent, but lateral rotation can scarcely by 
any accident occur. Here, however, the reverse holds true ; lateral 
displacement is difficult, while lateral rotation is comparatively easy 
of accomplishment. 

The majority of cases which occur, involving a disturbance of the 



Boston Med. and Surg. Journ., vol. xxxiv. p. 33(3, from Southern Journ. of Med. 



FKACTUKES OF THE FIBULA. 459 

relative position of the ankle-joint surfaces, are, I am satified, of this 
latter character, viz., lateral rotations within the capsule, rather than 
true dislocations ; and although the restoration of the joint surfaces 
to position is, in general, easily accomplished, yet, in consequence of 
either a fracture of the fibula or malleolus internus, or of a rupture of 
the internal lateral ligaments, it will almost always happen that some 
deformity will remain. The fragments of the fibula will fall inwards 
towards the tibia, and the foot, unsupported by either its fibula or its 
internal ligaments, will incline perceptibly outwards. Nor can this be 
wholly prevented, usually, by any mechanical contrivance. Indeed, it 
would be easy to demonstrate, as I have often done to my pupils, that 
even Dupuytren's splint, usually employed in this accident, must fail 
of success in a great majority of cases, since the subsequent deformity 
is due less to the fracture of the fibula and its consequent displace- 
ment than to the loss of the internal ligaments, which loss nature can 
seldom fully repair. The whole apparatus of the joint has suffered 
greatly, and its form and functions, therefore, are not likely to be 
completely restored, whether the fibula has participated in the injury 
or not. As further evidence of the correctness of this view, I will 
state that in three of the examples in which I have found the fractured 
fibula united and resting agaiust the tibia, the motions of the ankle- 
joint have been completely recovered. 

If, however, it were true that a fracture and displacement of the 
fibula is the sole or essential cause of the subsequent deformity, it 
would still be found often impracticable to avoid the maiming, since 
it would still remain impossible to lift the broken ends from the tibia, 
against which, or in the direction toward which, they are so prone to 
fall. Inversion of the foot does not accomplish it, nor have I ever 
been able to make anything but the most trivial impression upon the 
upper end of the lower fragment by pressure upon the lower extremity 
of the fibula. 

I think too much confidence has been placed in the efficiency of 
" Dupuytren's splint." I believe, indeed, that this splint ought gene- 
rally to be preferred as a means of support and retention after this 
accident, and I have myself usually employed it ; but I doubt whether 
it is able to accomplish all that its illustrious inventor proposed. 

Treatment. — I have already expressed my preference for Dupuy- 
tren's mode of dressing as a general 'practice, and especially would I 
give the preference whenever the accident has been accompanied with 

Fig. 192. 



Dupuytren's splint modified. 



an outward luxation of the foot, and a consequent rupture of the in- 
ternal lateral ligaments, or a fracture of the internal malleolus. 
This mode of dressing is essentially as follows : — ■ 
A pad, or long junk, made of a piece of cotton cloth, stuffed with 
cotton batting, is constructed of sufficient length to extend from the 



460 



FRACTURES OF THE FIBULA 



condyles of the femur to a point just above the malleolus internus. 
This pad must be about five or six inches in width, and thicker by 
one or two inches at its lower than its upper end. This is to be laid 
upon the inside of the leg, with its base or thickest portion resting 
against the tibia just above the internal malleolus. Over this pad is 
to be placed a long firm splint, extending also from above 
the knee to three inches beyond the bottom of the foot. 
With a few turns of a roller the upper end of the splint 
will now be made fast to the knee, and with a second 
roller the lower end must be secured to the foot. The 
application of this last bandage requires, however, 
some care in its adjustment. Its purpose is simply to 
rotate the foot inwards, while at the same time the tibia 
is pressed outwards ; and to this end it must be applied 
in the form of a figure-of-8 over both splint and foot, 
embracing alternately the heel and the instep. In 
order to be effectual, it must be drawn pretty firmly, 
and no portion of the bandage must pass higher than 
the malleolus externus. In some surgical books I have 
seen this apparatus represented with a roller embracing 
the whole length of the leg ; aud in others it is repre- 
sented as encircling the limb two or three inches above 
the malleolus (Fig. 193) ; but it is evident that these 
modes of dressing must defeat the great object which 
Dupuytren had in view, namely, the throwing out of 
the upper end of the lower fragment. 
When the limb is thus dressed, the knee may be flexed and the 
leg laid upon its outside, supported by a pillow, or upon its inside, as 
in the accompanying engraving (Fig. 194). 




Modified Dupny- 
ren's splint, incor- 
rectly applied. 



Fig. 194. 




Dupnytreu's splint as originally applied by himself. 



If it is only a fracture of the external malleolus, or if the fracture 
has occurred in the middle or upper third of the bone, this treatment 
is no longer appropriate, and it will generally be found sufficient to 
place the limb at rest for a few days upon a suitable cushion or upon 
a pillow. 

It is scarcely necessary to say that, since after this accident anchy- 
losis is so frequent, early and unremitting attention should be given 
to the establishment of passive motion in the joint. Indeed, I cannot 
but think that a desire to accomplish the indications recognized and 
urged by Dupuytren has led to the neglect of the indication which 
ought to have been regarded as of equal, if not of the greatest, im- 



FRACTURES OF THE TIBIA AND FIBULA. 461 

portance, namely, the prevention of contractions and adhesions around 
and between the joint surfaces. 

As a general rule, the dressings ought to be wholly laid aside by 
the end of the third or fourth week ; and although it may be well for 
a somewhat longer time to keep the foot turned in, by having it pro- 
perly supported as it lies upon the pillow, yet after this date I regard 
the use of splints and bandages as only pernicious. 



CHAPTEE XXXII. 

FRACTURES OF THE TIBIA AND FIBULA. 

Causes. — Probably four-fifths of these fractures are the results of 
direct blows or of crushing accidents, such as the kick of a horse, the 
passage of a loaded vehicle across the limb, the fall of heavy stones or 
timbers, &o. 

In an analysis of one hundred and eleven cases, I find the bones broken 
in the upper third from a direct cause four times, and from an indirect 
cause once. In the middle third forty have been referred to a direct 
cause, and two to an indirect ; and in the lower third thirty-nine to a 
direct cause, and eighteen to an indirect. An observation which does 
not sustain the remark of Malgaigne, based upon his analysis of sixty- 
seven cases, that fractures of the upper third are produced by direct 
causes alone, those of the middle third much more frequently by indi- 
rect causes, and that those of the lower third are especially due to 
indirect causes. Direct causes produce a large majority of the frac- 
tures of the lower third, but the proportion is smaller than in the 
middle third. 

Of the indirect causes, falls upon the feet from a considerable height 
— as from a scaffolding, or from the top of a building — are by far the 
most common. Four times I have found the bones broken by muscu- 
lar action alone, as in the following example : — 

Mrs. W., of Buffalo, aged about twenty-five years, and weighing at 
this time nearly two hundred pounds, was descending her door-steps 
with an infant in her arms, when, the step being covered with ice, she 
slipped and fell, breaking her right leg just above the ankle. Mrs. W. 
says she felt and heard the bones snap before she touched the steps. 
Of this she is certain. 

We found the tibia broken obliquely, the fragments being quite 
movable, but not much, if at all, displaced. The limb was dressed 
with a carefully moulded and well-padded gutta-percha splint, and 
then laid in a pillow upon the bed. Mrs. W. experienced unusual 
pain from the fracture for several days, for the relief of which we were 
compelled at times to permit her to inhale chloroform. She was of a 
nervous temperament, and had frequently resorted to chloroform 
before to relieve neuralgic pains. The limb became very much 



462 FBACTUEE3 OF THE TIBIA AXD FIBULA. 

swollen, and remained so for a week or two. ]S"o extension was ever 
employed. 

Within the usual time, the bones united in perfect apposition, and 
in about four months she was able to walk without any halt. 

Pathology, Symptoms, &c. — TVe have seen that fractures of both 
bones through some part of the lower third are most frequent. Thus, 
of one hundred and fifty-five fractures, eleven belonged to the upper 
third, forty-five to the middle, and ninety-three to the lower. In six 
cases the two bones were broken in different divisions. It is probable 
that in this analysis some errors have occurred, and that in a larger 
proportion than here stated the two bones have given way at opposite 
extremities, since it is often difficult, and sometimes quite impossible, 
to determine precisely where the fibula is broken ; but the analysis is 
sufficiently correct to illustrate the much greater frequency of fractures 
of the lower third, and also the fact that the two bones generally 
break nearly on the same level ; usually the point of fracture in the 
tibia is between two and three inches above the joint, where the bone 
is the weakest. 

In an examination of twenty museum specimens I have found both 
bones broken at the same point, or within two or three inches of the 
same point, sixteen times, and at extreme points four times ; and in 
these last examples the tibia has always been broken in the lower 
third, while the fibula has been broken in the upper third. 

In seventeen of the fractures mentioned as belonging to the lower 
third only the malleolus of the tibia was broken, while the fibula was 
broken two or three inches above its lower end. Some of these were, 
perhaps, examples of dislocation of the ankle. 

I have seldom seen a transverse fracture of the tibia, except in its 
lower or upper extremity, in the expanded portions of the bone, and 
even in those examples which we are accustomed to call transverse, 
because they are sufficiently so to prevent any sliding or overlapping 
of the fragments, there has existed, generally, a marked inclination of 
the line of fracture in one direction or another. 

The examples of fracture produced by muscular action have, with- 
out an exception, occurred in adults. Three of them were in the lower 
third of the leg, and one in the middle third. I think they were, all 
of them, nearly transverse, since they never became much, if at all, 
displaced. 

Most of the fractures of the tibia produced by falls upon the feet 
are very oblique, and the direction of the fracture is generally down- 
wards, forwards, and inwards ; but I have found almost every con- 
ceivable variation from this general rule. 

The fracture in the fibula is even more constantly oblique than the 
fracture in the tibia ; but this is a point of very little practical conse- 
quence, and one which we can seldom determine positively, unless one 
of the fractured ends protrudes through the flesh. 

Compound and comminuted fractures are more frequent here than 
in any other of the bones of the body. My tables, which have rejected 
all fractures demanding immediate amputation, most of which are 
compound, do not for this reason give a just idea of their proportion 



FRACTURES OF THE TIBIA AND FIBULA. 463 

to simple fractures; yet even in these tables, of one hundred and 
seventy-two fractures, sixty-two were compound, and also, generally, 
more or less comminuted. Of eighty cases reported by W. W. Mor- 
land, of Boston, from the Massachusetts General Hospital, and in 
which the character of the accident is recorded, thirty-nine were com- 
pound. 1 

The symptoms indicating a fracture of both bones of the leg are the 
same which are usually present in other fractures, namely, mobility, 
crepitus, shortening of the limb, distortion, swelling, &c. Generally 

Fie. 195. 



Compound and comminuted fracture of the leg. 

the lower end of the upper fragment projects in front, and can be seen 
or felt; but in some instances the swelling follows so rapidly that it is 
impossible to feel distinctly the point of fracture, and its existence can 
only be determined by the crepitus, mobility, and shortening of the 
limb, or, perhaps, by the marked deformity or deviation from the 
natural axis. 

The shortening, where it exists at all, varies at the first from a line 
or two to a half or three-quarters of an inch. Generally, it is about 
half an inch. 

Prognosis. — The average period of perfect union in twenty- nine 
cases, including those in which union was delayed by extraordinary 
causes beyond the usual time, was forty days. The general average 
under ordinary circumstances may be stated at about thirty days. 

Union has been delayed in seven cases, five of which were simple 
fractures, and two were compound. The longest period was seventeen 
weeks. 

F. C. T., of Erie Co., N. Y., set. 35, had an oblique, simple fracture 
of both bones, in the upper third, caused by jumping from a buggy, in 
June, 1852. 

The limb was dressed with lateral splints, compresses, and bandages, 
and laid upon a pillow. 

Eight weeks after the fracture had occurred, the gentlemen in 
attendance wished me to see the limb with them. I found Mr. T. still 
in bed, and the fragments not at all united. 

1 Transac. of Mass. Med. Soc. for 1840; Fractures, by A. L. Pierson. 



464: FRACTURES OF THE TIBIA AND FIBULA. 

Mr. T. had enjoyed average health heretofore, but he was never 
very robust. When I was called to see him he lopked pale ; his skin 
was cold and moist, pulse 120, and appetite poor. The broken leg 
and foot were greatly swollen. The swelling was cedematous. Con- 
siderable excoriations existed ou the back of the leg. The fragments 
were quite movable, and were overlapped three-quarters of an inch. 

We agreed that the patient ought, as soon as possible, to be got out 
of bed, so as to enable him to recover his strength, which had sadly 
declined. To this end, a gutta-percha splint was made to fit accurately 
the whole length of the leg; and, having attached a large number of 
tapes, it was to be secured upon the limb. Several times each day it 
was to be removed, and the limb bathed with brandy and water. 
Gradually, also, the limb was to be brought down to the floor, and the 
patient be made to sit up, and, as soon as possible, he was to walk 
with crutches, or to ride. 

JSTov. 4, 1852, Mr. T. visited me at my house. The directions had 
been followed implicitly. About two weeks after my visit he rode 
out, and in about nine weeks, or seventeen weeks from the time of 
the fracture, the bones were found united. His health and strength 
were quite restored, and the limb was no longer cedematous, It was 
found to be straight, or with only a slight projection of the upper 
fragment in front of the lower, and shortened three-quarters of an 
inch. 

A gentleman, set. 33, from Bergen, N. Y., was struck by a billet of 
wood on the 3d of August, 1856, breaking his left leg nearly trans- 
versely, three and a half inches above the joint. The fracture was 
simple. A surgeon was called immediately, who applied bandages and 
side splints, and then laid the limb over a double inclined plane. At 
the end of six weeks the dressings were removed, but the bones had 
not united. Four years after the accident, this gentleman consulted 
me. I found him in good health, but no union had yet taken place. 
This is the only example, except where amputation or death inter- 
posed, in which the union has been so long delayed as to entitle it to 
be considered as a case of non-union. My own observation would, 
therefore, incline me to think that, while non-union is a rare event in 
fractures of the leg, delayed union is more frequent than in most 
other fractures. 

It has once occurred to me to see a complete non-union of the fibula 
after a period of several years, while the tibia had united well. This 
circumstance occasioned no inconvenience to the patient, and was not 
known to him until I had made the discovery. 

A little more than one-half of those cases in which an accurate 
note of the result has been made, have been found to be more, or less 
shortened by overlapping, namely, sixty-one cases out of one hundred 
and ten. The greatest amount of shortening in any one case has been 
one inch and a half; and the average shortening of the sixty-one cases 
has been half an inch and a fraction over. This analysis includes both 
simple and compound fractures; but a pretty large proportion of the 
simple fractures have also been found shortened, as in the following 
extreme illustration : — 



FRACTURES OF THE TIBIA AND FIBULA. 465 

John Granger, of Hungerford, England,. set. 43, was tripped by a 
stone while walking, breaking his right leg through its lower third. 
Fracture simple and oblique. It was treated by Eichard Barker, 
surgeon, of Hungerford, England. He employed only side splints. 

Two years after, I found the leg shortened one inch, the upper 
fragment riding upon the front and inner side of the lower. 

Generally, when a shortening has occurred, I have found the upper 
fragment in front of the lower, and oftener a little upon the inner than 
upon the outer side. 

The deviation from the natural axis of the limb has been noticed 
by me in a good many instances. Seven times the lower part of the 
limb has fallen backwards, and five times it has, in a degree much 
less marked, inclined inwards. Once I have seen it inclined outwards, 
and twice forwards. 

Ulcers upon the back of the heel, seen by me seven times, as a result 
of undue pressure upon this part, have, however, been presented but 
three times in a case of simple fracture. 

It is not very unusual to find, also, over the exact point of frac- 
ture, and after the lapse of several months, or even years, an ulcer, or 
sinus, which is due sometimes to the presence of a small fragment of 
bone which has remained in the wound from the time of the accident, 
or to a thin scale which has subsequently exfoliated. In other cases 
it is due to the prominence of the salient angle when the lower part 
of the limb inclines considerably backwards, and in still other cases, 
no doubt, to the general dyscrasy of the system, and to the same 
causes which produce chronic ulcers in the lower extremities where 
only the skin has been originally injured. I have reported elsewhere 
examples of this complication existing after five months, two and 
three years, 1 and in the remarkable case which I shall now briefly 
relate an ulcer existed at the end of twenty-three years. 

Thurstone Carpenter, when four years old, received an injury, 
breaking both bones of one of his legs near its middle. The fracture 
was compound. It was dressed and treated by an excellent surgeon, 
then residing in Buffalo, but long since dead. 

Twenty-three years after the accident, Mr. Carpenter called upon 
me on account of a paralysis of his lower extremities, which had 
recently occurred. He stated that from the time of the fracture until 
within about one year an open ulcer had existed over the seat of 
fracture, and that soon after it had closed over completely he began 
to lose the use of his limbs. During the time it was open, small scales 
of bone have frequently been thrown off. The limb is half an inch 
shorter than the other, but straight. 

A gentleman residing in Quincy, Chautauque Co., N. Y., had his 
tibia and fibula broken near the ankle-joint in the year 1844, by the 
passage of a carriage-wheel across his limb. The skin was a good 
deal lacerated. The wounds, however, healed kindly, and the broken 
bones united in the usual time without any apparent deformity ; but 
the limb continued swollen and painful, until finally suppuration took 

1 Trans. Amer. Med. Assoc. Report on Deformities after Fractures. 



466 FRACTUEES OF THE TIBIA AXD FIBULA. 

place. After twelve j^ears of great suffering, I amputated the leg near 
its middle, from which time he made a speedy recovery. I found the 
lower end of the tibia inflamed, softened, and expanded, and contain- 
ing in its interior about three ounces of pus, but no sequestrum. 

Anchylosis of the knee or ankle-joint may follow as a result of the 
accident or of improper treatment; and at one or both of these joints 
I have found more or less anchylosis at the end of nine months, one 
year, six years, twenty five, thirty, and forty years. Generally, how- 
ever, it disappears in a few weeks, and seldom remains to any con- 
siderable extent in the knee-joint after the dressings have been 
removed two or three weeks; but an Irishman called upon me in 
1853, whose leg had been broken about three inches below the knee- 
joint six years before. It was a simple fracture. A surgeon in 
Ireland had treated the case. I found the limb shortened one inch 
and a half, the fragments being overlapped and displaced backwards 
at the point of fracture. The knee was also partly anchylosed. I 
could not learn what the treatment had been. 

In other cases, where no permanent anchylosis has followed, the 
ankle-joint has been occasionally painful, and subject to swellings, 
after the lapse of many years. 

After all that has been said as to the occasionally serious nature of 
the consequences of these accidents, as shown in the shortening of the 
limbs, in their deviations from their natural axes, in the stiff ankles, 
ulcers, and abscesses, it must be still admitted that in another point of 
view these results are not extraordinary, and may hereafter continue 
to be fairly anticipated in a certain proportion of cases, even under 
the best management; since it must be understood that more fractures 
of the leg are attended with serious complications than of any other 
limb ; and that while many produce death rapidly from the severity 
of the shock, and very many are condemned at once to amputation, a 
large number of those which are saved have been in that condition 
which has rendered the application of bandages or splints impossible 
for many days. Indeed, not a few of these crooked limbs may still 
be presented as real triumphs of the art of surgery, inasmuch as by 
consummate skill alone have they been saved. 

Treatment. — Without being able, in a case which presents so many 
forms and complications, to establish any rule of universal applica- 
tion, I nevertheless do not hesitate, after considerable experience, in 
declaring a plan of treatment which in my opinion ought to be adopted 
with only occasional exceptions, that is, I mean to say, in simple 
fractures. The plan to which we choose to give so general a prefer- 
ence is well known as that recommended and practised by Pott, the 
distinguished surgeon of St. Bartholomew's Hospital ; and with only 
slight modifications, it will be found applicable to probably nine- 
tenths of all the simple fractures of the leg, and to some of the com- 
pound fractures. 

The apparatus will consist of two splints with pads and bandages. 

First we are to construct a splint, made of a thin piece of board, 
long enough to extend from a little above the knee to a point two 
inches beyond the sole of the foot, about seven inches in width, and 



FRACTURES OF THE TIBIA AND FIBULA. 467 

reaching forwards at the lower end, so as to support the foot. This 
splint is to be covered heavily with cotton batting, in order that it may 
fit all the inequalities of the outer side of the leg and foot, taking, 
however, especial care that there should be a depression at a point 
corresponding to the external malleolus, so deep as that even when 
the limb is bound down to the splint the malleolus shall not touch. 
The splint with its padding must then be covered with cotton cloth 
neatly sewed on. 

The remaining splint may bq made of binder's board, felt, or gutta 
percha; but in either case it need not extend higher than the bend of 

Fig. 196. 




Long splint for treatment of a fracture of the leg in Pott's position. 

the knee or lower than the upper margin of the malleolus internus, 
unless the fracture should be near one of these extremities ; and in 
case it does extend lower, the same precautions must be taken to 
protect the malleolus internus from pressure. Whichever also of the 
materials is employed, the splint never ought to be applied directly 
to the skin, but a thin pad made of a few layers of cotton sheeting 
covered with cotton cloth must be laid underneath. 

It is seldom that I have found it necessary or useful to apply any 
bandages directly to the skin ; but in certain cases of compound frac- 
tures where dressings have been applied, which needed support and 
protection, a bandage has been of service. The roller, unless the 
patient is a child, whose limb can be easily lifted and managed, is 
always objectionable; but the many-tailed bandage, made of narrow 
strips of cloth, laid upon each other, as we have already described in 
bur general remarks upon bandages, &c, is much to be preferred. 

Having made these preparations, we proceed to flex the leg to a 
right angle with the thigh, and by the hands make extension and 
counter-extension as much as the patient will bear, or as much as 
may be necessary to restore the fragments to place. If the fracture 
is compound, and the point of bone protrudes through the skin, it is 
often difficult to replace it. That is, we are unable to overcome the 
action of the muscles sufficiently to make the limb of its natural 
length, and for this reason, mainly, we are unable to get the point of 
bone beneath the skin. If we cannot then " set" the bone, or bring 
the ends into apposition, and this will be the fact pretty often, we still 
have no apology generally for leaving the bone outside of the skin. 
First, an attempt must be made to accomplish this reduction by pull- 
ing aside the skin with the fingers, or with a blunt hook. This simple 



468 FRACTURES OF THE TIBIA AND FIBULA. 

procedure has often succeeded with me in a moment, when others 
have been trying in vain to accomplish the same end by pulling upon 
the limb. If this fails, then the skin should be cut sufficiently to 
allow the bone to retire, or if the point is sharp, and especially if it is 
stripped of its periosteum, it may be sawn off. Kesecting thus the 
end of an oblique fragment does not generally affect in any degree 
the length of the limb, or interfere with a prompt and perfect cure, 
but, on the contrary, it often is advantageous in every point of view. 

Having restored the fragments to their places as well as we may, 
the limb is laid carefully on its outside upon the long wooden splint. 
We shall now find it necessary generally to add two or three thin 
pads, in order to supply vacancies which we have not perfectly pro- 
vided for in the preparation of the splint. Generally we shall also 
see the necessity of placing a pretty thick pad under the outer margin 
of the foot or toes, so as to bring the great toe in line with the inner 
edge of the patella and spine of the tibia. The other side splint is 
now laid along the inner or tibial side of the limb, and with successive 
turns of a roller, or with a number of narrow and separate strips of 
cloth, the whole are bound together, and the limb is left to repose 
upon its outer side. 

The patient may, if necessary, lie upon his back, but it is better 
that he should be turned a little toward the side of the broken limb. 
The danger of twisting the fragments upon each other is lessened by 
lying upon the same side with the broken limb, but I have frequently 
permitted patients to lie upon their backs, and found no such result. 
If the long under splint extends a little way upon the thigh, and is 
well fastened to the thigh, the twist cannot very well occur. 

By adopting this general plan of treatment we avoid all chances of 
gangrene or swelling of the foot from excessive ligation, and it is to 
these accidents, especially, that the remarks of Dr. Norris, already 
quoted, are applicable. The large size and irregular form of- the 
bones of the leg, the small amount of muscular tissue covering them, 
especially near the articulations, the severity of the injuries to which 
they are liable, with their remoteness from the centre of circulation — 
these circumstances, altogether, render them exceedingly exposed to 
injury from the too great or unequal pressure of splints or of bandages ; 
and it has often occurred to myself, as it has to Dr. Norris, to find the 
skin vesicated, or even ulcerated and sloughing, when the patients are 
first admitted to the hospital ; a condition which, in nine cases out of 
ten, is due to the mal-adjustment of the splints, or to the tightness of 
the bandages. 

If bandages are used under the splints, and next to the skin, they 
must.be applied very moderately tight, and loosened or cut as the 
swelling augments ; and, from the first day of treatment to the last, 
the surgeon must be careful to loosen or tighten the dressings when 
the swelling increases or subsides, just as the prudent boatman trims 
his sails to the rising and falling breeze. 

Dr. Krackowitzer presented to the New York Pathological Society, 
June 10, 1863, a leg which he had amputated for gangrene occasioned 
by tight bandages. A boy, five years old, sustained an injury of the 



FRACTURES OF THE TIBIA AND FIBULA. 469 

ankle-joint, which his medical attendant pronounced a fracture of the 
fibula, and for which he applied only a tight bandage. The child 
suffered a good deal after the bandage was applied, and the following 
morning the toes were blue, but the doctor paid no attention to this 
circumstance. The pain subsided on the third day, and on the fourth 
the bandages were removed, and the limb found to be gangrenous. 

The specimen showed that the fibula was not broken, but that there 
was a fissure or crack in the lower part of the shaft of the tibia. 1 

The following case, which has been communicated to me by Dr. 
Fuller, of Wyoming, IS". Y., with permission to make such use of it 
as I choose, is sufficiently pertinent for the instruction of others, and 
deserves a public record : — 

A man, ast. 71, fell from a tree, striking upon his foot, Aug. 27, 
1855, producing a backward dislocation of both the tibia and fibula 
upon the os calcis, and also a fracture of both bones of the leg a few 
inches above the ankle. 

An empiric took charge of this unfortunate man, and immediately 
applied lateral splints and a firm roller from the toes to the knee. 
Notwithstanding the remonstrances and prayers of the patient to have 
the bandage loosened, it was kept on until the ninth day, when the 
doctor cut the bandage upon the top of the foot, and it was found 
vesicated. Ignorant, however, as to the cause of this vesication, and 
of the danger which it threatened, he omitted to loosen the remainder 
of the bandages, and the limb was left in this condition until the 
twenty-third day, when Dr. Fuller being called, and having removed 
all the dressings, found the integuments covering the whole foot dead 
and dried clown to the bones. The dislocations had not been reduced. 
Soon after this the limb became oedematous, and on the twenty-seventh 
of October the leg was amputated by Dr. Barrett, of Le Eoy ; from 
which time the patient recovered rapidly. 

But it is to the advantages of the posture recommended by Pott 
that I wish especially to direct attention. The position hitherto gene- 
rally preferred by surgeons has been that in which the limb rests 
upon its back, either in a box or upon a double inclined plane; but all 
of the examples of ulcers upon the heel which I have seen have been 
after treatment in this position. Indeed, it is almost impossible for 
this accident to happen in any other way, and it has therefore never 
occurred to me to see it in cases treated by Pott's method. It is true 
that, with great care, such a result' might generally be prevented while 
the leg is resting upon its calf, yet experience shows that it is by no 
means easy to avoid it always. And if, in our anxiety to obviate this 
evil, we place pads underneath the tendo-Achillis, above the heel, we 
incur the risk of pressing the fragments forwards, and of compelling 
them to unite with the whole lower part of 'the leg inclined backwards. 
I have mentioned already that this has happened, in cases that have 
subsequently come under my observation, no less than seven timef, 
while an attempt to correct this fault by placing the support under 
the heel has either produced ulcers of the heel, or driven the lower 
part of the limb in the opposite direction. 

1 Krackowitzer, Arner. Med. Times, Nov. 7, 1863. 



470 FRACTURES OF THE TIBIA AND FIBULA. 

The same thing — that is, a deviation backwards or forwards — might 
happen in any posture, but I am sure it is much less liable to in Pott's 
position than in any other. 

Then, a^ain, a twist or rotation of the lower fragment is more liable 
to take place when the toes point upwards, and the limb rests upon the 
calf and heel, than when the limb reposes upon its side. In the one 
case it is resting upon a narrow surface, with the whole weight of the 
foot disposing it to either eversion or inversion, while in the other it 
lies upon a broad surface, with the foot entirely at rest, and demanding 
no extraordinary support. 

In short, Pott's position is less irksome to the patient, and vastly less 
troublesome to the surgeon. Ugly and crooked limbs are sometimes 
inevitable, and they are often the consequences of unskilful manage- 
ment, or of inattention on the part of the surgeon; but, other things 
being equal, the best legs have, in my experience, come out of Pott's 
position, and the worst out of the double inclined plane and the box. 

As to the tendency of the upper fragment to rise at the point 
of fracture, it depends, no doubt, upon the usual direction of the 
fracture, and the action of the muscles both in front and behind ; so 
far as the former circumstance is the cause — that is, the direction of 
the line of fracture — no position is sufficient to remedy it; and in rela- 
tion to the action of the muscles, the indications are as easily and 
naturally fulfilled with the limb upon its side as upon its back. Gene- 
rally the leg needs to be flexed upon the thigh ; but if the fracture is 
high up, and its direction is obliquely downwards and forwards, it 
must be made nearly or quite straight, so as to overcome the action 
of the anterior muscles of the thigh, acting, through the ligamentum 
patellae, upon the upper fragment. The simple rule which I recom- 
mend and adopt is, to flex or extend the limb more or less until it is 
ascertained in what position the apposition of the fragments is moat 
complete. 

In such few cases as demand or warrant a resort to extension and 
counter-extension, a double inclined plane furnishes the most conve- 
nient mode for its accomplishment ; but it is only occasionally that, in 
fractures of the leg, permanent extension and counter-extension can 
be employed ; an assertion which, however much it may excite surprise, 
experience will prove true. If the fracture is near the middle of the 
leg, quite remote from the points upon which the appliances for ex- 
tension, &c, are to be made fast, and the inflammation is moderate, 
something may be done in this way ; but when the point of fracture 
approaches the ankle-joint, as it actually does in a great majority of 
cases, a gaiter, made of any material whatever, if it has sufficient firm- 
ness to overcome completely the action of the muscles, will inevitably 
cause congestion and swelling, accompanied sooner or later with great 
pain and with ulcerations, and simply because the extension is made 
directly upon parts already tender and inflamed from the accident 
itself; and when we add to this complete and violent ligation of the 
limb near the seat of fracture, a similar ligation of the limb just below 
the knee, for the purpose of making counter-extension, as is done in 



FEACTURES OF THE TIBIA AND FIBULA. 



471 



what is known among American surgeons as "Hutchinson's splint" 1 
(Fig. 197), we are prepared to understand how the worst consequences 
may ensue. I have once seen, when this abominable apparatus had 
been used, a complete ring of ulceration below the knee, and another 
as complete around the foot and ankle. The limb was twice girdled, 
and yet the surgeon thought he was performing a duty for the omission 
of which he would scarcely have been regarded as excusable. 

Fig. 197. 




j ; : '_ : ■ —w 




If! 



i^!!i!!!' : '^Jii!!i!il 1: :ii! : liilJ1 : !1;i|i , ' i l ':i. ■.. ■ ": ~~~ i!r'!i l 'r i f l l ! i :| !!'!jii'| l 'l l l| l !T' I i'' ? ii 



James Hutchinson's splint for extension, etc., in fractures of the leg. (From Gibson.) 

Jarvis's adjuster, a still more mischievous, inasmuch as it is a more 
powerful instrument, operating in a similar manner, has been pro- 
ductive of .like consequences; but Jarvis's adjuster is liable to the 
additional objection that by its great weight it drags off the limb, 
turning the toes outwards, an objection which no care or diligence can 
generally overcome. 

I could wish that neither of these appliances would ever again be 
impressed into the service of broken legs. 

Neill, of Philadelphia, Crandall, of New York, and Daniels, of 
Broome Co., N. Y., have each sought to overcome some of the diffi- 

Fig. 198. 




John Weill's apparatus for fractures of the leg requiring extension and counter-extensiou. 

culties in the way of making extension in fractures of the legs, by 
substituting adhesive plaster for the usual extending or counter- 
extending bands. 

Says Dr. Neill: "For simple fractures of both bones of the leg, at- 



Eleruents of Surgery, by John Syng Dorsey, vol. i. p. 181. Philadelphia, 1S13. 



472 



FRACTUEES OF THE TIBIA AND FIBULA. 



tended with shortening and deformity not easily overcome, the limb 
should be placed in a long fracture-box with sides extending as high 
as the middle of the thigh, and a pillow should be used for compresses. 

"The counter-extension is made by strips of adhesive plaster, one 
inch and a half in breadth, secured on each side of the leg below the 
knee, and above the seat of fracture, by narrower strips of plaster 
applied circularly. The end of the counter-extending strips may then 
be secured to holes in the upper end of the sides of the fracture-box, 
by which the line of the counter-extension is rendered nearly parallel with 
the limb. 

"The extension is also to be made by adhesive strips, in a mode 
which is now well known and understood. The ends of the extending 
bands may be fastened to the foot-board of the box." 1 

Dr. Neill further remarks : "In compound fractures of the leg, short- 
ening and deformity are often difficult to overcome, as is well known 

Fig. 199. 




John Neill's apparatus for compound fractures of the leg. 

to experienced surgeons. In such cases we may wish to dress the 
wounded soft parts, and, at the same time, maintain a certain amount 
of extension and counter-extension. 

" This can be readily accomplished by having the sides of the frac- 
ture-box sawed in two parts at the knee, so that the sides of the box 
above the knee, from the upper ends of which the counter-extension 
is made, need not be disturbed during the dressing, while that portion 
of the side of the box, corresponding to the leg, may be opened at 

Fig. 200. 




Gilbert's Box for Compotxd Fractures of the Leu. 
1. The four, counter-extending adhesive strips, as if encircling the knee and upper part of leg. 2. 
The two extending adhesive strips crossing at the bottom of the foot, ready to be applied to the foot. 3. 
Tourniquet. 

pleasure, without diminishing the tension of the extending or counter- 
extendino- bands." 



Philadelphia Med. Exam., vol. xi. p. 5S0, 1855. 



FEACTUEES OF THE TIBIA AND FIBULA. 



473 



In compound fractures of the leg, Dr. Gilbert recommends a modifi- 
cation of the common fracture-box. In this apparatus the foot-board 
is omitted, and a block for the reception of the frame of the tourniquet 
is substituted. Each side of the box consists of three separate seg- 
ments. Of these the upper and lower are permanently screwed to the 
bottom-board, and the central one is attached by hinges. By this 
arrangement there is full access to the wound, which may be dressed 
from day to day without disturbing the extension and counter-exten- 
sion, maintained by the permanently attached upper and lower seg- 
ments. 

The following wood-cuts (Figs. 201, 202, 203) are intended to illus- 
trate the apparatus invented by K. 0. Crandall, for the purpose of 

Fig. 201. 




Section of Crandall's apparatus, applied to the limb ; showing adhesive plaster counter-extending bands 

and gaiter for extension, &c. 

Fig. 202. 




Posterior view of the lower portion of Crandall's apparatus. 
Fig. 203. 




Crandall's apparatus complete. The counter-extending straps are passed over a block of wood sup- 
ported above the knee, to prevent their pressure upon the sides of the knee. 

making permanent extension. The extension is represented as being- 
made by a gaiter, but Dr. Crandall leaves it to the choice of the sur- 
geon whether he shall employ the gaiter or adhesive straps. 1 



1 Crandall, Phil. Med. Journ., vol. iv. p. 193, Jan. 1856 ; also Transac. of Med. 
Assoc, of Southern and Central New York, 1855, pp. 81, 82. 

31 



474 FRACTURES OF THE TIBIA AND FIBULA. 

Without intending to deny to these contrivances much ingenuity 
and considerable practical value, I am far from conceding that they 
will be found capable of overcoming altogether the action of the mus- 
cles where the ends of the fragments do not support each other. Their 
mode of action is such that they can scarcely do more than to steady 
the limb, and if they operate upon the fragments at all in the direction 
of their axes, it must be only in the most inconsiderable degree. The 
adhesive plasters are substituted for the circular knee bands and the 
gaiters, with a view to avoid ligation ; but in order to do this they 
must not encircle the limb, but only be laid parallel to its long axis. 
The leg of an adult, or that portion to which the adhesive plasters 
can be applied, supposing the fracture to be exactly at the centre, 
may be sixteen inches, that is, eight inches for extension and eight for 
counter-extension ; but when we employ the same means for extension 
in fractures of the thigh, we find it necessary to apply the straps over 
the whole of these sixteen inches, the entire length of the leg, or they 
will not hold. It will be apparent also that we cannot use even the 
eight inches which we have, for the purpose of argument, allowed 
these gentlemen in fractures of the leg. There must be at least a 
space of eight inches between the ends of the two opposing straps in 
order that they may operate at all upon the fragments ; indeed, I do 
not believe that even then their influence would reach beyond the 
skin to which they were directly applied ; but if a space of eight inches 
is left, only four remain for the straps at either end ; and this is an 
amount of surface wholly insufficient for our purpose. What, then, 
shall we do when the fracture is near one of the extremities of the 
bone ? These gentlemen seem to have forgotten, moreover, that the 
whole leg is tender, and that the skin easily vesicates. In short, they 
have not seen the many points of difference between the application 
of these means in fractures of the thigh and leg, and which, while 
they allow us to accomplish all that we could desire with the one, are 
of little or no use in the other. We shall then always come to the 
same conclusion ; whatever means we may employ to make permanent 
extension in fractures of the leg, we must either fail to accomplish 
all that we desire, or incur the hazards incident to complete and firm 
ligation of the limb ; and if the preference is given to any form of 
apparatus to accomplish these ends, it must be to some form of the 
double inclined plane, by which we may at least avoid ligation in the 
upper part of the limb, the counter-extension being made against the 
under surface of the thigh while it is resting upon the thigh piece ; or 
to one of the long straight thigh splints, which will enable us to make 
the counter-extension from the thigh and perineum. 

The paste, starch, or dextrine bandage I have used in a few cases 
of simple fracture of the leg within a day or two after the accident, 
but not unless I felt certain from the nature of the injury that no 
swelling was to occur. It is only in those fractures in which the bones 
do not become displaced, or only very slightly, that I would recom- 
mend its employment at a period so early. 

But as soon as the fragments have united in almost any form of frac- 
ture of the leg, it will not be improper to put on the paste bandage and 



FRACTUKES OF THE TIBIA AND FIBULA 



475 



Fig. 204. 




allow the patient to go about carefully upon crutches ; or if, indeed, 
the fragments have not united, but the swelling has completely sub- 
sided, and the wounds have healed, 
it cannot be regarded as unsafe to 
adopt this practice. The young sur- 
geon cannot, however, be too much 
impressed with the danger of this 
mode of treatment, as a universal or 
general plan, employed without dis- 
crimination. Its most devoted ad- 
vocates, Seutin, Yelpeau, Gamgee, 
and others, will not deny the neces- 
sity of caution in its use ; and the nu- 
merous accounts of crooked limbs, 
ulcerations, and even of gangrene, 
which have been attributed, fairly, 
I think, to one or another of the 
forms of the immovable dressing, 
ought to be sufficient to place us 
fully upon our guard. 1 

The majority of such cases as, 
in my judgment, may be safely 
intrusted to a paste bandage, will 
also do well enough in almost anjr 
form of dressing; and not a few of r .( From Fergusson.) 
the examples of simple fracture of 

the leg without much if any displacement, which have come under 
my notice, I have treated by simply inclosing the leg neatly in a 
pillow, tied against the limb with tapes, only that I have taken care 
that the pillow shall be so fastened around the foot and leg as to keep 
the limb steady. At other times I have laid outside of the pillow, 
thus arranged, two broad side splints, and bound these against the 
limb, with the pillow interposed ; or I have, in the summer, used splints 
made of rolls of straw inclosed in pieces of cloth — "straw junks." In 
all these cases I have laid the leg upon its back, and I cannot say but 
that the limbs have done well. 

If a double inclined plane is used, I prefer either a plain apparatus, 
such as we have already described as in use for fractures of the thigh, 
constructed of boards, joined together by hinges opposite the knee, 
and with an upright foot-board, upon which a carefully arranged and 
thick cushion has been placed, or the more elegant double inclined 
plane of Liston. 

In using Liston's apparatus, it must not be inferred that the knee is 
always to be bent. The apparatus is designed to be used occasionally 
as a straight splint ; and there will be found many cases of fractures 
of the legs in which the straight position will be most suitable : this 
is especially true of such fractures as, occurring just below the knee- 



Immovable" apparatus applied to the leg. 



1 Accidents resulting from the use of the immovable apparatus. Amer. Journ. Med. 
Sci., vol. xxv. p. 460, Feb. 1840 ; from Gazette des Hopitaux. 



476 



FRACTURES OF THE TIBIA AND FIBULA 



joint, have the line of fracture directed obliquely downwards and for- 
wards. But there are many compound fractures which demand the 

Fig. 205. 




Liston's double inclined plane ; applied to the leg in a case of compound fracture. (From Miller.) 

same extended position ; and in nearly all cases where this form of 
apparatus is used as a double inclined plane, the lower end of the 
splint should be elevated so that the heel shall not be much below the 
level of the knee. 

Bauer's wire splints, used also for side splints, when they are formed 
to fit the limb accurately, possess some advantages which must recom- 
mend them to the attention of surgeons ; but neither these splints nor 



Fig. 206. 




Louis Bauer's wire splints for the leg. 1 

any others, however accurately fitted, ought to be applied directly to 
the naked skin. They require always the interposition of a well- 
padded lining. 

Boxes are rarely useful except in certain compound fractures. They 
are heavy and awkward machines, which prevent the patient from 
moving readily in bed ; or which, being fixed, if he does move, allow 
the upper fragment only to descend, or to move upon the lower as a 
fixed point. If used at all, they ought generally to be suspended or 
made to move on a suspended railway. But, however they are ar- 

1 Bauer. Buffalo Medical Journal. April, 1S57, vol. xii. 



FEACTUEES OF THE TIBIA AND FIBULA 



477 



ranged, the limb is a great part of the time concealed from sight, and 
the surgeon is prevented from making use of such means to rectify 

Fig. 207. 




Swing box or " cradle. ' ' (From Skey. ) 

deviations in the line of the bone, as he would probably have other- 
wise employed. 

The swing invented by James Salter, of London, is constructed so 
as to allow not only a lateral motion, but also a more complete motion 
in the direction of the axis of the limb, by which the danger of push- 
Fig. 208. 




Salter's cradle. (From Fergusson.) 

ing the fragments upon each other is obviated. This is accomplished 
by the rolling of two pulley-wheels upon a horizontal bar. The case 
in which the leg rests may be made of metal or of wood, and the frame 
of iron, for the sake of lightness and strength. 

Dr. Hod gen, of St. Louis, suspends the box over a pulley placed 
transversely, so that by drawing the rope to the right or to the left, 
the box may be turned upon either side. 



FRACTURES OF THE TIBIA AXD FIBULA 



Fracture-box, vrith movable sides. 



These boxes are sometimes filled with bran, the bran being closely 
packed upon all sides so as to support the limb uniformly and gently. 
This method of treating compound fractures of the leg was first sug- 
gested by J. Ehea Barton, of Phila- 
Fig. 209. delphia, 1 and has been much used in 

tthe Pennsylvania Hospital. It pos- 
sesses the advantage of affording a 
perfect protection against flies in the 
HH|| summer season, and of absorbing the 
^HP^^^^^S matter as it escapes. Whenever any 
IB portion of it becomes soiled by blood 
f r or pus, it may be dipped out with a 
spoon, and its place supplied with 
fresh bran. The support which it 
gives to the limb is also uniform 
without being at any time excessive, and Dr. Coates states that the 
escape of blood in rapid hemorrhages has been known to increase the 
bulk of the bran sufficiently to arrest the bleeding by its accumulated 
pressure. 

In whatever position the leg is placed, and with many of the forms of 
apparatus which we have enumerated, it will 
be found necessary to protect the limb from 
the weight of the bedclothes by some contri- 
vance similar to that figured in the accom- 
panying drawing. 

Malgaigne, who declares that the whole 
world knows how impossible it is, in an im- 
mense majority of cases, to overcome the pro- 
jection of the superior fragment when the limb 
is placed in the extended position (over a double inclined plane), and 
who affirms that neither Pott's position, nor Dupuytren's modification 
of it, will do much if any better, nor, indeed, that Laugiers plan of 
cutting the tendo Achillis possesses in this respect any real advantage, 
concludes at last to resort to a new and really ingenious method, the 



Fig. 210. 




Wire rack for fracture of leg. 




Malgaigue"s apparatus for oblique fractures of the leg. (From Malgaigne.) 

value of which, also, he claims to have already fully demonstrated. 
Ilis apparatus consists simply of a steel band of sufficient size to en- 



1 Barton, Amer. Journ. of Med. Sci., vol. xvi. p. 31, and vol. xix. p. 515. 



FRACTURES OF THE TIBIA AND FIBULA, 



479 



circle three-fourths of the limb, at the two extremities of which are 
two horizontal mortises through which a band is passed, and which 
may be buckled upon itself behind. The centre of the metallic arch, 
in front, is penetrated with a firm, metallic screw, terminating in a 
very sharp point, and which is moved by a flat thumb-piece. 

The limb being laid over a double inclined plane, and the pads 
being carefully adjusted, as we have already directed when speaking 
of other forms of apparatus, and the limb properly extended, the 
apparatus of Malgaigne is placed over the limb, with the sharp point 
of the screw resting upon the upper fragment, a few lines above the 
point of fracture ; and at the same moment that this point is pressed 
firmly down to the bone, the fragments being held together by an 
assistant, the strap is buckled as tightly as possible under the splint. 
A few turns of the screw will now make its point penetrate more 
deeply into the bone, and insure the most complete apposition of the 
broken extremities. " This is accomplished," says Malgaigne, " with 
very little pain to the patient ;" and, as will be seen, the steel arch 
effectually prevents any ligation of the limb. 



Fig. 212. 




Malgaigne's apparatus applied. 



(From Malgaigne.) 



In some cases of extreme deformity of the legs consequent upon 
badly united fractures, resection of the bones has been practised with 
more or less success. 

The first case of which I have seen any mention made, where the 
bones were actually resected, is reported by Charles Parry, of Indian- 
apolis, Ind. A young man, set. 15, having broken his leg near its 
middle, the fragments united, from some cause, nearly at right angles 
with each other. Some years afterwards, on the 15th day of January, 
1838, Dr. Parry operated, by removing a wedge-shaped portion from 
both the tibia and fibula. The recovery was tedious, but satisfactory. 1 

Mr. Key, of London, made an operation of this kind upon a gentle- 
man who had suffered a fracture of the right tibia from a musket-ball. 
The limb was nearly useless, since he could only bring his toes to 
the ground, Mr. Key operated in Oct. 1838, and when the report of 

1 Parry, Amer. Journ. Med. Sci., Aug. 1839, p. 334. 



480 FRACTURES OF THE TIBIA AND FIBULA. 

the case was made five months subsequently, the patient was doing 
well. 1 

In Sept. 1840, Dr. Mutter, of Philadelphia, made a similar operation 
upon a patient, whose leg was shortened three inches and a half, and 
very much deformed : by which operation, when the recovery was 
complete, the shortening was considerably reduced. 2 

Cases may occur which will justify a resort to these extreme mea- 
sures, or in which they may be preferred to amputation ; but an exa- 
mination of the several examples reported will show that these ope- 
rations are not unattended with danger to the life of the patient ; 
indeed, in this respect, amputation has greatly the advantage. If, 
moreover, the surgeon expects, by this method, to lengthen a limb 
much, where it is merely overlapped and shortened, he is, I am certain, 
destined to disappointment, at least in all cases where sufficient time 
has elapsed for the bones to have become firmly united. I have never 
myself refractured a bone, but I have several times met with cases of 
old fractures newly broken, and I have constantly observed that I 
could never, in the end, make it any longer than it was before the 
last fracture. The muscles had contracted to that point, and their 
contraction would not be overcome. In the case reported by Mutter, 
he believed that he stretched the muscles two inches. With all de- 
ference for the skill and honesty of this gentleman, I think that he was 
mistaken. 

If, however, the object of the operation is to straighten the limb, 
then no doubt it may be sometimes accomplished ; and in some degree 
also by the straightening of the limb the shortening may be over- 
come ; but, in our opinion, such procedures ought to be reserved for 
extraordinary circumstances. 

An instructive case of refracture is reported by Dr. Horner, of 
Philadelphia, in the Medical Examiner. The limb had been broken 
eight weeks, and was quite crooked, but was not very firmly united, 
and Dr. Horner having refractured it, was able at once to restore it 
to a nearly straight line. 3 



CHAPTEE XXXIII. 

FRACTURES OF THE TARSAL BONES. 

Causes. — The astragalus is generally broken by a fall from a height, 
the patient having struck upon the bottom of the foot. Monahan, in 

' Key, Amer. Journ. Med. Sci., Aug. 1839, p. 339, from Guy's Hospital Reports, 
April, 1839. 

2 Mutter, Amer. Journ. Med. Sci., April, 1842, p. 359. Three similar cases may 
also be found in the Oct. No. for 1841, and the April No. for 1842 of the same journal, 
in which the operations were made by Portal, of Palermo. Malgaigne mentions two 
other examples. 

3 Horner, New York Journ. Med., May, 1851, p. 432. 



FEACTUEES OF THE TAESAL BONES. 481 

an analysis of ten cases, found it had been broken by a fall upon the 
foot nine times, 1 and only once by a crushing accident. 

The calcaneum is also occasionally broken by violent lateral pres- 
sure, but much more often by a fall upon the foot, or rather upon the 
heel. In some instances both heel-bones have been broken at the 
same moment ; but Malgaigne has collected eight cases of fracture of 
this bone by muscular action, as in jumping upon the toes, the pos- 
terior portion of the bone being thus violently acted upon by the 
tendo Achillis. South, in his Notes to Chelius, has mentioned two 
other cases, one of which was seen by Lawrence, and has been reported 
in the second volume of the Lancet. This person had received the 
injury by jumping off a stage-coach. The fragment was found to be 
drawn upwards slightly, but not so far as to prevent crepitus when 
the muscles on the back of the leg were relaxed. The other example 
mentioned by South is a cabinet specimen contained in the museum 
of St. Bartholomew's Hospital. The fracture had taken place just 
below the attachment of the tendo Achillis, but the upper fragment 
was not displaced. 2 Mr. Cooper mentions two other cases, both pro- 
duced by violent efforts on the part of the patients to sustain them- 
selves when falling. In one of these the fragment was immediately 
drawn up three inchs. 3 

The other bones of the tarsus are generally broken by crushing 
accidents, such as the fall of heavy weights upon them, by the passage 
of loaded vehicles, &c. 

Pathology. — The astragalus often, indeed generally, escapes without 
injury in those crushing accidents which break many or most of the 
other bones of the foot, and, as we have seen, it is seldom broken 
except when the patient has fallen upon the bottom of his foot ; but 
at the same moment, the foot being turned forcibly out or in, a dislo- 
cation of the tibia takes place, and the fibula is broken. In nine of 
the cases collected by Monahan, one or the other of these forms of 
dislocation had occurred, in eight of which the dislocation was com- 
pound. The direction of the fracture is found to vary greatly ; thus, 
it has been found broken in its length antero-posteriorly, in its breadth 
or transversely, and in one instance it has been divided nearly hori- 
zontally, so as to separate the upper face completely from the lower. 
Sometimes it suffers a species of impaction, the fragments being ac- 
tually driven into each other; at other times, as in one case related 
by Amesbury, the bone may be split without the occurrence of any 
displacement. 

The calcaneum also may be broken in any direction, and it is equally 
with the astragalus liable to impaction, by which its vertical diameter 
is sensibly diminished, while its transverse diameter is increased. If 
the fracture is a consequence of muscular action, the line of fracture is 
always posterior to the astragalus, and in some cases only that portion 

! Fracture of the astragalus, with an analysis of the recorded cases of this injury. 
An inaugural thesis presented to the faculty of the Buffalo Med. Col., March, 1S5S, 
by Bernard Monahan, M. D. 

2 South, Notes to Chelius's Surgery, vol. i. p. 639, Amer. ed. 

3 B. Cooper's ed. of Sir Astley, Amer. ed., p. 311. 



482 FRACTURES OF THE TARSAL BONES. 

is broken off to which the tendo Achillis has its attachment. It may 
be broken also vertically, directly underneath the astragalus, in which 
case the lateral and interosseous ligaments will prevent anything more 
than a slight displacement of the posterior fragment. When the 
fracture takes place posterior to the lateral ligaments, the detached 
fragment is liable to be drawn very far from the body of bone, even 
to the extent of four or five inches, and possibly further when the leg 
is extended upon the thigh and the foot flexed upon the leg. Con- 
stance relates a case in which the tuberosity, having been broken off 
by a direct blow, was drawn up five inches. 1 

Fractures of the calcaneum produced by contraction of the sural 
muscles are generally simple, but those which result from a crushing 
of the bone are more often compound. The same remark is applicable 
also to the other bones of the tarsus, the fractures of which, being 
only produced by direct blows, are generally complicated with exter- 
nal wounds. 

Symptoms. — All fractures of the bones of the tarsus demand especial 
care in their diagnosis, since only a few of the usual signs of fracture 
are in a majority of the cases presented. The explanation of this 
fact will be found in the number, size, and strength of the bones of 
the tarsus, and in their close and firm union by ligaments, by which 
they give to each other a mutual support, so that the fracture of a 
single bone does Dot necessarily or usually result in displacement or 
deformity, and even crepitus is with difficulty detected ; and when we 
consider, moreover, that the fracture is generally produced by great 
violence, directly applied, in consequence of which the foot in most 
cases becomes rapidly and enormously swollen, we shall understand 
the true nature of the difficulties which are usually presented in the 
way of an accurate diagnosis. 

Of all the usual signs of fracture, crepitus alone is pretty generally 
present, but even this often fails to tell us which bone is broken, and 
still more often does it fail to inform us as to the direction and extent 
of the bony lesions. 

If the whole or a portion of the tuberosity of the calcaneum is sepa- 
rated by the action of the muscles, and the fragment is drawn up- 
wards, it may be discovered in its new position, and the heel will be 
flattened or shortened, but no crepitus can be felt unless the fragments 
are again brought in contact. 

Treatment. — Not any of the fractures of the tarsal bones in them- 
selves demand the use of splints, and it is only when complicated with 
a dislocation of the ankle and fracture of the fibula that it is proper 
to employ apparatus of this sort ; certainly the exceptions to this rule 
must be very rare ; so that our practice in these cases will be confined 
chiefly to the prevention and reduction of inflammation. The limb 
must be placed in the most easy position, and cold water lotions assidu- 
ously applied. This will be the sum of the treatment demanded during 
the first few days after the receipt of the injury in probably all cases 
of simple fracture, and in many cases of compound fracture. 

1 Constance, Amer. Jo urn. Med. Sci., vol. v. p. 222, Nov. 1829, from the Midland 
Med. and Surg. Reporter. 



FRACTURES OF THE TARSAL BOXES. 483 

If single bones, or fragments of single bones, are displaced to any 
considerable extent, and there is an external wound communicating 
with the fracture, I have no doubt it would be best in all cases to re- 
move at once by dissection the projecting bone, even although it were 
possible, or perhaps easy, to force it back again to its place, as has 
been done successfully by Ashhurst, of Philadelphia. 1 The same 
rule I would apply to examples of fracture uncomplicated with any 
external wound, if the fragments were very much displaced, and could 
not by the application of moderate force be replaced, since the bone 
left to project would prevent the patient from ever wearing a boot 
with comfort, and would entail as much weakness upon the limb as 
would be likely to follow from its complete separation. But such 
cases as I have last supposed are exceedingly rare ; indeed, I have 
never met with a simple fracture of a tarsal bone accompanied with 
displacement. 

Norris has, however, reported a case of fracture of the astragalus 
accompanied with displacement of about one-half of the bone, but 
without any lesion of the soft parts. This was in the person of a man 
set. 30, who was admitted into the Pennsylvania Hospital on the 26th 
of Sept. 1831. "An hour previous to admission, while decending a 
ladder, he slipped and fell in such a manner as to throw the entire 
weight of his body upon the outer part of his left foot. Upon exami- 
nation, the foot was found to be turned inwards and nearly immovable. 
A slight depression existed immediately below the lower end of the 
tibia, and there was a considerable hard and rounded projection on the 
outer part of the foot, a little below and in front of the extremity of 
the fibula. The skin covering this projection was reddened, but not 
excoriated. There was no fracture of either bones of the leg." 

These appearances led Drs. Norris and Barton, under whose care 
the patient was placed, to regard the accident as a simple luxation of 
the astragalus forwards and outwards ; and a short time after admis- 
sion efforts were made to reduce it. " This was done after relaxing in 
as great a degree as possible the muscles of the leg, by fixing the knee, 
and having assistants to keep up extension, by seizing the heel and 
front part of the foot ; at the same time the bone being pushed inwards 
and toward the joint by the surgeon. These efforts were continued 
for a considerable time, but had no effect in changing the position of 
the bone. 

" Six hours afterwards, Drs. Huston and Harris saw the patient in 
consultation, when efforts were again made at reduction, which not 
proving more effectual than in the first trial, the excision of the bone 
was determined on. 

" The patient being properly placed, an incision was made through 
the integuments, parallel with the course of the tendons, commencing 
a short distance above the projection on the foot, and extending down 
far enough to expose fairly the astragalus and its torn ligaments. 
The bone was then seized with forceps, and easily removed after the 

1 Ashliurst, Amer. Journ. Med. Soi., April, 1862. 



484 FRACTURES OF THE TARSAL BOXES. 

division of a few ligamentous fibres that continued to connect it to 
the adjoining parts. 

" Very little hemorrhage occurred, two small vessels only requiring 
the ligature. 

" After removal, it was discovered that about one-half of the surface 
which plays in the lower end of the tibia had been fractured, and 
remained firmly attached to the extremity of that bone, and as it was 
judged that the efforts to remove this would be likely to produce more 
injury to the joint than would arise from allowing it to remain, no 
attempt was made to extract it. 

" The joint being carefully sponged out, the sides of the incision 
were brought accurately together by means of sutures and adhesive 
straps, after which simple dressings and a roller were applied, and 
the foot, restored to its natural situation, placed in a fracture-box." 

Subsequently that portion of the astragalus which was permitted to 
remain, having become carious and loosened, was removed also. 

The case continued to do badly ; all the bones of the tarsus, and 
even the lower ends of the tibia and fibula, becoming eventually cari- 
ous; and on the 27th of March, 1853, more than a year and a half 
after the receipt of the injury, the leg was amputated; but no healthy 
action ensued, and the patient soon died. 1 

The result of this case can scarcely be regarded as having settled 
anything in reference to the value of the procedure which I have 
recommended. For reasons which seemed satisfactory to the sur- 
geons who made the operation, only one-half of the broken bone was 
removed ; whether the result would have been different if the whole 
had been at once taken away, we cannot now determine. I have 
related it, however, as the only example of a simple fracture with 
displacement which I have been able to find upon record; and in this 
case, several surgeons of merited distinction concurred in the opinion 
that the protruding fragment ought to be removed. 

A fracture of the posterior portion of the calcaneum, especially when 
it has been produced by muscular action, constitutes an exception to 
fractures of the tarsal bones generally, and demands usually that 
apparatus of some kind should be employed in its treatment. 

In order to replace the posterior fragment when displaced, or to 
maintain it in apposition until a bony union is accomplished, it will 
be necessary to shorten the gastrocnemii by flexing the leg upon the 
thigh and extending the foot upon the leg. But to retain the limb 
in this position it will be expedient always to employ apparatus. A 
very simple contrivance, however, will generally answer all the indi- 
cations. A bandage, padded strap, or a stuffed collar may be fastened 
about the thigh just above the knee, and made fast to the heel of a 
slipper by a tape (Fig. 213). The apparatus is the same which has 
been recommended for a rupture of the tendo Achillis. 

In addition to this, the limb ought to be covered from the foot 
upwards as far as the knee with a snug roller, underneath which, on 
each side of and above the detached fragment, ought to be placed 

1 Norris, Amer. Journ. Med. Sci., vol. xx. p. 379. 



FRACTURES OF THE METATARSAL BONES. 



485 



suitable compresses, the object of the roller being to diminish mus- 
cular contraction, and the compresses being intended to retain the 
detached piece in contact with the main 
body of the bone. Some surgeons have 
not found it necessary to flex the leg upon 
the thigh, and they have contented them- 
selves with extending the foot upon the 
leg, and confining it in this position by 
a splint of wood or gutta percha laid 
along the front of the leg, ankle, and foot. 
In still other cases, the fragment has 
shown so little disposition to become 
displaced as to render no precautions of 
any kind necessary, except to impose 
upon the patient complete quiet, with 
the limb resting upon its outside and 
flexed, as in Pott's fracture of fibula. 

As soon as the inflammation has suffi- 
ciently subsided, passive motion must 
be given to the ankle, in order to pre- 
vent, as far as possible, the anchylosis 
which is an almost constant result of 
these accidents. Indeed, the patient is 
fortunate who recovers a tolerable use 
of his foot after the lapse of many 
months, nor can he be assured that the 
inflammation will leave these bones 
and their dense fibrous envelops for 
a long period, and that it may not re- 
sult in caries of more or less of the tarsal bones, demanding finally 
amputation of the whole foot. 

We have not intended to speak in this place of those severer acci- 
dents, accompanied with comminution and extensive laceration, which 
forbid the hope of saving the foot, and for which immediate amputa- 
tion is the only proper resource, but which constitute, in fact, the great 
majority of all the fractures of the tarsal bones. 




Apparatus for fracture of the tube- 
rosity of the calcaneuin. 



CHAPTEE XXXIV. 

FRACTURES OF THE METATARSAL BONES. 

These bones can scarcely be broken except by direct blows, and 
the great majority of their fractures are the results of severe crushing 
accidents, such as render amputation sooner or later necessary. Of 
those which do not demand amputation, by far the largest proportion 
are compound fractures ; of which class the following example will 
serve as an illustration. 

A man in the employ of one of the railroads which connect with 



486 FRACTURES OF THE METATARSAL BONES. 

this city was run over by a loaded car on the 14th of June, 1856, 
crushing his right arm so as to render its immediate amputation 
necessary. I found also a compound comminuted fracture of the 
fourth metatarsal bone of the right foot. Considerable hemorrhage 
occurred from the wound, but this ceased spontaneously. Cool water 
dressings were diligently applied, without splints or bandages, and 
although some inflammation and suppuration ensued, the parts finally 
healed over and the fragments united, with only a slight backward 
displacement at the seat of fracture. 

When only one bone is broken, the displacement is usually very 
trivial ; but when several are broken, it may be considerable. Mal- 
gaigne relates an example of this latter accident in which, the three 
middle bones being broken by the wheel of a carriage, and the integu- 
ments being badly torn and bruised, it was found impossible to retain 
the fragments in place. The patient recovered, and was able to place 
the foot well to the ground, but the proximal fragments continued to 
project upwards upon the top of the foot to such a degree as to require 
a special shoe. 

In a majority of cases the direction of the displacement is backwards 
or upwards, especially when the middle metatarsal bones are the sub- 
jects of the fracture. 

I have in my cabinet a second metatarsal bone broken obliquely 
near its middle, with only a very slight displacement of the lower 
fragment backwards; and also the cast of a bone which has united 
with an enormous backward projection. 

In one instance I have seen the metatarsal bone of the little toe 
cut in two with an axe, and the fragments united in about thirty days, 
but with the lower fragment slightly displaced outwards. 

Delamotte relates a case also in which the first four metatarsal 
bones were cut off; and complete union was accomplished on the 
fortieth day : at the end of two months the patient walked without 
lameness. 

If the fragments are not displaced, nothing is required except that 
the foot shall be kept at rest, and the inflammation controlled by 
suitable means. 

In case, however, a displacement exists, it ought to be remedied, if 
possible, since, if only very slight, it may become the source of a 
serious annoyance. If the fragments project upwards, they interfere 
with the wearing of a boot, and if they sink toward the sole, the skin 
beneath is liable to remain constantly tender, and the patient may 
thus be seriously maimed for life. 

In case the displacement is not due to the action of the muscles, 
but only to the nature and direction of the force producing the frac- 
ture, or to entanglement of the broken ends, and it is likely to cause 
any of the inconveniences which I have mentioned if permitted to 
remain, it will be advisable at once to employ considerable force in 
the way of pressure, or to elevate the fragments through an opening 
previously made upon the dorsum of the foot, calling to our aid even 
the saw or the bone cutters, if necessary. After which the fragments 
may be retained in place by carefully applied pasteboard splints and 
compresses. 



GUNSHOT FRACTURES 487 



CHAPTEE XXXY. 

FRACTURES OF THE PHALANGES OF THE TOES. 

If fractures of the other bones of the foot are generally of such a 
character as to require immediate amputation, these fractures demand 
this extreme resort still more often. Our experience, therefore, in the 
treatment of fractures of the phalanges of the toes is extremely limited. 

Lonsdale observes that it is not uncommon to find great irritation 
arise after fracture of the great toe ; an inflammation extending along 
the absorbents on the inside of the leg to the groin, causing abscesses 
to form in different parts of the limb, and producing sometimes great 
constitutional disturbance. An illustrative case has come under my 
own observation at the Buffalo Hospital of the Sisters of Charity. 
The patient, Morgan McMann, set. 18, was admitted Dec. 23, 1853, 
having several days before received an injury upon the great toe 
which contused the flesh severely and broke the first phalanx. He 
was then suffering from severe pain in the foot and leg, and the 
absorbents were inflamed quite to the groin. Poultices being applied 
to the foot and cool lotions to the limb, the inflammation soon sub- 
sided, but not until a portion of the toe had sloughed away. Even- 
tually also it became necessary to remove some portion of the phalanx, 
which had died ; after which the wounds healed kindly. 

When any of the smaller toes are broken, it will be found easier to 
support the fragments by a broad and long splint which shall cover 
the whole sole of the foot and all the toes at the same time, than to 
attempt to apply a splint to the broken toe alone. If, however, we 
prefer this latter mode, a thin piece of gutta percha will be found 
altogether the most convenient material for the purpose. 

If the great toe is broken, its great breadth may prevent any dis- 
placement, and a well-moulded gutta-percha splint will generally 
secure a perfect and rapid union. 



CHAPTEE XXXYI. 

GUNSHOT FRACTURES. 

Gunshot fractures have already been considered, more or less in 
detail, in the several portions of this work, wherever it seemed to be 
necessary to call especial attention to them. The only justification, 
therefore, for a further allusion to this class of accidents must be found 
in the special interest which they possess at this moment in my own 
country. 



488 GUNSHOT FRACTURES. 

I propose to condense my remarks upon this subject rather into the 
form of aphorisms, than to give at length the opinions of surgeons and 
their discussions; accordingly, this chapter will constitute only a brief 
resume of what I have myself observed, and of the well-attested obser- 
vations of others. To which will be added a few general statistical 
statements, drawn chiefly from the published records of the late war. 

Causes. — Gunshot fractures are caused by a great variety of missiles, 
such as musket and rifle balls, solid shot and shell, grape, canister, 
shrapnel, chain and bar shot, fragments of iron, stone, splinters of 
wood, &c. &c. The only qualities which these missiles possess in 
common is, that they are all projected by the elastic power of gun- 
powder, and generally strike the body with great force ; and that they 
cause fractures by direct violence — seldom, if ever, by counterstroke. 

Eound, smooth balls frequently impinge upon bones without caus- 
ing a fracture, for the reason that they are easily deflected ; and this 
happens especially when they are not moving with great velocity. 

Conical rifle-balls seldom fail to fracture the bones which lie in their 
direct course; never, perhaps, when, at the moment of contact, the ball 
is moving with its average velocity. The peculiar destructiveness of 
this missile is due to its weight, momentum, and form. 

Canister, grape, shrapnel, solid shot, shells, chain and bar shot are 
still more destructive ; generally tearing the limbs from the body in 
such a manner as to render readjustment and restoration impossible. 

Pathology. — These fractures may be simple, compound, comminuted, 
or complicated ; and in addition to these common varieties of fractures 
there is occasionally presented an example of simple "perforation," or 
mere penetration of the bone without fissure or other fracture ; and 
still more frequently are seen examples of perforation with fissures. 

Probably ninety-nine per cent, of all gunshot fractures are both 
compound and comminuted ; the comminution being, in general, ex- 
cessive. 

As in gunshot wounds of the soft parts it has been generally 
observed that the point of entrance is more round, more smooth, and 
somewhat smaller than the point of exit, and that the tissues are a 
little depressed at the entrance, while they are slightly protruded at 
the exit, so also in gunshot fractures it will often be found that the 
side of the bone on which the ball has entered, or upon which it first 
impinged, is less comminuted than the opposite side ; and, if it is a 
"perforation," that the opening is smaller upon the one side than upon 
the other ; that the edges are slightly depressed upon the one side, 
and elevated or protruded upon the other ; and, finally, that numerous 
small, as well as some large, fragments of bone have been carried into 
that portion of the track of the wound which lies between the bone 
and the point of exit of the missile. 

When a ball fractures the shaft of a long bone, although the blow 
may have been received three, four, or even six inches from an arti- 
culation, the comminution, or a single longitudinal fissure, may some- 
times be found extending into the joint. These fissures, or splittings 
of the shaft, often extend also a long distance up or down, without 
terminating in the joint. 



GUNSHOT FKACTUKES. 489 

Perforations without fissure occur most often in the broad bones 
of the pelvis, in the scapula, or in the spongy extremities of the long 
bones. In the latter, however, it is exceedingly rare to find perfora- 
tion without fissure. 

Perforations with fissure are pretty common in the head of the 
humerus and in the head of the tibia ; they occur also, but less often, 
in the lower ends of the femur and tibia, in the trochanteric portion 
of the femur, and in the head of the femur. We wish to be under- 
stood to say that fissures occur less often at the points last mentioned, 
simply because perforations are there less common. It must be 
known that if perforations do occur at these points, a splitting or 
fissure communicating with the joints is almost inevitable. A mis- 
understanding here would lead to a very fatal error in many cases. 

Prognosis. — In general it may be stated that gunshot fractures of 
the upper extremities do not demand amputation, and that similar 
injuries in the lower extremities do demand amputation. 

This statement is very broad, and cannot be understood except by 
a consideration of these accidents somewhat in detail. Thus: — 

Gunshot fractures of the clavicle, scapula, of the shaft of the hu- 
merus, of the shafts of the radius and ulna, and of the carpal, meta- 
carpal, and phalangeal bones, notwithstanding these bones have 
suffered extensive comminution, do not demand amputation : they 
will in most cases eventually unite, and give to the patients tolerably 
useful limbs. If, however, at the same time that the shaft of the 
humerus, or of the radius and ulna, is thus broken, the large nervous 
trunks are torn asunder, so that the extremity is cold and insensible, 
the limb cannot probably be saved, nor, if it could be, would it be of 
any value. Destruction of the main artery supplying the limb dimi- 
nishes the chance of its being saved, but does not, in the case of the 
upper extremity, necessarily demand amputation. 

Penetration of the shoulder-joint by a musket or rifle ball, pro- 
ducing a fracture of the head of the humerus or of the glenoid cavity 
of the scapula, demands amputation when either the axillary artery 
or axillary nerves are injured; but resection can generally be prac- 
tised with a reasonable chance of success when the arteries and nerves 
are untouched. Kesection is also made successfully at the shoulder- 
joint in some cases where larger missiles have traversed the joint, 
such as canister, fragments of shell, &c. 

Penetration of the elbow-joint by a large shot, or by a Minnie rifle 
ball, the missile fairly entering or traversing the joint, demands am- 
putation when the main arterial and nervous supplies are cut ofi^ and 
resection, generally, when both remain uninjured. Resection may be 
attempted at the elbow-joint, also, in some cases where, the nervous 
supply remaining good, only one of the principal arterial trunks is 
cut off. 

Frequently a ball strikes the outer or inner condyle of the humerus, 
making but a small opening into the joint, and producing only slight 
comminution, and in such cases we often save the limb with more or 
less anchylosis, and without resection. 

The remarks which we have made in reference to gunshot fractures 
32 



490 GUNSHOT FRACTURES. 

of the elbow-joint apply, almost without qualification, to the same 
accidents at the wrist-joint. 

For gunshot wounds with fracture of the carpal, metacarpal, and 
phalangeal bones we seldom practise either resection or amputation, 
unless the soft parts are almost completely torn away. 

The prognosis which, as we have now seen, is so favorable in the 
"upper extremities, will be found very different in the lower extremi- 
ties ; indeed, it is almost reversed. Thus : — 

Gunshot fractures of the shaft of the thigh, of the shafts of the tibia 
and fibula, and of the tarsal bones, generally demand amputation ; or, 
to be more precise, gunshot fractures of the head and neck of the 
femur almost always terminate fatally under amputation or excision, 
and equally under treatment as fractures, that is, where an attempt is 
made to save the limb without interference with the knife. The same 
accidents in the upper third or the shaft of the femur are generally 
fatal; but if the main artery and the principal nerves are uninjured, 
the life is, in general, less hazarded by an attempt to save the limb 
than by amputation. In the middle third, under the same circum- 
stances, the chances may be considered equal, as between amputation 
and the attempt to save the limb by apparatus ; in the lower third the 
chances are in favor of amputation. 

The above statements in relation to fractures of the femur are based 
mainly upon my own experience, and have been carefully considered. 

I have seen no resections of the knee-joint, and but few of the shaft 
of the femur, after gunshot fractures, which have not terminated fatally ; 
and I am convinced that they should never be attempted in fractures of 
the thigh, unless it be that case which presents so little hope in any 
direction, viz., gunshot fracture of the head or neck of the femur. 

Gunshot fractures of the shafts of both tibia and fibula demand 
amputation where the comminution is extensive, or the pulsation of 
the posterior tibial artery is lost, or the foot is cold and insensible. 
We do not mean to say that some limbs thus situated have not been 
saved, but only that the attempt to save such limbs greatly endangers 
the life of the patient, while amputation at or below the knee is rela- 
tively safe. 

Amputation is the only safe expedient in deep penetrating wounds 
of the tarsal bones produced by missiles of the size of musket-balls 
or larger. The only exceptions, which can safely be made, are in 
cases where balls have opened partially and superficially these articu- 
lations. 

Eesections at the ankle-joint are much more hazardous than ampu- 
tations, and scarcely to be preferred, in army practice, to attempts to 
save the foot without surgical interference. 

Treatment. — While considering the prognosis in these accidents, I 
have necessarily spoken of the treatment in certain cases ; especially 
with a view to the propriety of amputation or resection. It remains 
only to speak briefly of the treatment of those cases in which we may 
attempt to save the limb without resection, properly so-called ; for we 
must not forget that pretty often we find it necessary to remove small, 
loose fragments of bone by the finger, or by the aid of the knife, or to 



GUN-SHOT FRACTURES. 491 

resect sharp points with the saw or the bone-cutters, when we do not 
practise " resection," in the sense in which this term is usually em- 
ployed by surgical writers. 

I shall take the liberty, in this connection, of reproducing what I 
have written elsewhere in relation to gunshot fractures, since it com- 
prises nearly all that seems necessary to be added upon this subject. 1 

"If an attempt is made to save a limb badly lacerated and broken, 
certain conditions in the treatment are necessary to success. 

"All projecting pieces of bone which cannot be easily replaced and 
are not firmly attached to the soft parts, must be at once cut or sawn 
away. 

" All foreign substances, such as fragments of balls or other missiles, 
pieces of cloth, wadding, dirt, &c, must be removed. 

"Any portion of integument, fascia, or muscles, which are entangled 
in the wound, and prevent a thorough exploration, or may obstruct 
the free escape of blood or of matter, must be freely divided. 

"Counter-openings must be made at once, or at an early period 
after the formation of matter, to insure its easy escape. 

" The limb must be placed in an easy position, and not confined by 
tight bandages, or forcibly extended by apparatus. 

" The inflammation must be controlled by constitutional and local 
means, and especially by the use of water lotions whenever its em- 
ployment is practicable." 

If joints are implicated seriously, and an attempt is still made to 
save the limb, the joint surfaces must be laid freely open, so as to 
prevent all possibility of the confinement of blood, serum, or pus ; and 
the joint must be placed perfectly at rest, without adhesive straps, 
bandages, or any apparatus which shall compress the limb or em- 
barrass its circulation. 

I do not know that it is necessary to speak more particularly of the 
treatment of gunshot fractures, unless it be to say that I still give the 
preference, in fractures of the femur, to the straight position. In 
general I have preferred Buck's apparatus, with moderate extension ; 
and by moderate extension is to be understood such as may be effected 
with from five to ten pounds. Hodgen's straight splint, or " cradle," 
has been found exceedingly useful, and much preferable to any form of 
double-inclined plane, whether suspended or not. The cradle is simply 
a skeleton box, of the length of the thigh and leg, made of light strips 
of wood. Across the two upper bars are laid, transversely, cloth 
bands, upon which the limb is laid at full length. 2 

As supplementary to this chapter, it seems proper to add a brief 
resume of the statistics of the war of the rebellion just closed, drawn 
from the report of the Surgeon-General, made in November, 1865. 3 

Of 4,167 gunshot wounds of the face, 1,579 were accompanied with 
fractures of the facial bones. Of these latter 107 died, and 891 re- 

1 Treatise on Military Surgery, by Frank Hastings Hamilton. 1 vol. 8vo. Published 
by Bailliere Brothers. New York, 1861 ; also enlarged ed. of same work in 1S65. 

2 Hodgen, Treatise on Military Surg., by the author, p. 408. 

3 Circular No. 6, Surgeon-General's Office. 



492 GUNSHOT FRACTURES. 

covered. The remainder are undetermined. Secondary hemorrhage 
is said to have been the most frequent cause of death. 

Of 187 examples of gunshot injuries of the spine (not including 
those in which the chest or abdomen was penetrated), 180 died. Six 
of those reported as having recovered were examples of fracture of 
the transverse or spinous processes. The seventh is that of a soldier 
wounded at Chicamauga, September 20th, 1863, by a musket-ball, 
which fractured the spinous process of the fourth lumbar vertebra, and 
penetrated the vertebral canal. The ball and fragments of bone were 
extracted, and one year after he was reported as " likely to recover." 

Of 359 gunshot wounds of the pelvis (not including those in which 
the abdominal cavity was penetrated), 77 died and 97 recovered. In 
the remainder the result is not ascertained. In 256 cases the ilium 
alone was injured; in 19, the ischium alone; in 12, the pubes; in 32, 
the sacrum ; and in 40 cases the lesions extended to two or more por- 
tions of the innominata. Pyaemia was a frequent cause of death. 

Of 1,689 gunshot fractures of the humerus, 436 died, and 1,253 re- 
covered. Nine hundred and ninety-six of these 1,689 Cases were 
treated by amputation or resection, with a mortality of 21 per cent. 
In 693 cases the conservative treatment was adopted, with a mortality 
of 30 per cent. 

Of 68 cases in which attempts were made to save the limb after 
gunshot injury of the hip-joint, without resection, all died. (I have 
seen two cases of successful treatment of these accidents by the con- 
servative plan, and others have been reported.) 

Twenty amputations at the hip-joint gave two successful results. 
(The Surgeon-General's report includes a third — Dr. Fenner's case — 
but this is now known to be an error.) 

Thirty resections furnished three successful results. (The report 
includes two more resections — Cases 19 and 30— which must be rejected 
as not belonging to this class.) 

Three hundred and thirty cases of gunshot fracture of the upper 
third of the shaft of the femur, in which neither amputation nor resec- 
tion was practised, gave a mortality of 71.81. Thirty-two cases in 
which amputation was made gave a mortality of 75 per cent. Twenty- 
two in which resection was made, gave a mortality of 81.18. (We 
have rejected three cases given in the report as cured. Two of 
these were resections of the head, and one was merely a "rounding off 
of sharp edges.") 

Two hundred and thirty -two cases of gunshot fractures of the mid- 
dle third, treated without amputation or resection, gave a mortality of 
55.46. Ninety-three treated by amputation gave a mortality of 54.83. 
Fifteen treated by resection gave a mortality of 86.66. 

One hundred and seventy-three gunshot fractures of the lower third, 
treated without amputation or resection, gave a mortality of 57.79. 
Two hundred and forty-three amputated — mortality 46.09. Two 
resected — both died. 

Of 308 gunshot wounds of the knee-joint, with or without fracture, 
treated without amputation or resection, 258 died — mortality 83.76. 
Of the 50 which recovered there were, however, only six or eight in 



GUNSHOT FRACTURES. 493 

which the testimony is unequivocal that the joint was opened. Of 452 
amputated, 331 died — mortality 73.23. Of 10 resected, 9 died — mor- 
tality 90 per cent. 

Of 696 gunshot fractures of the leg, 169, or 24 per cent., were fatal. 

No analyses have been made of fractures of the smaller bones. 

It is much to be regretted that in these comparative analyses 
of the treatment of gunshot fractures by the three methods it is not 
stated whether the amputations or resections were primary or secondary. 
In all secondary amputations and resections, which, for aught that 
appears, may have constituted a majority of the whole number, the 
conservative treatment had been tried and had failed, and the deaths 
which followed ought in justice to be charged to conservatism and not 
to the operation. As the reports now stand, they are of little or of no 
value in determining the relative value of conservative and operative 
treatment. 

From the reports of the Confederate army, as published in the Con- 
federate States Medical Journal, we learn that of 221 cases of gunshot 
fractures of the thigh treated without amputation or resection, 105 
died, and 116 recovered. The shortest period of recovery was 41 clays ; 
the longest, 255 days ; the average, 104 days. The shortest period of 
fatal termination was one day; the longest, 185 days ; average, 52 days. 
Greatest shortening, five inches; least, half an inch ; average, one inch 
and nine-tenths. 1 

Of 507 amputations for gunshot fractures of the thigh, 250 recov- 
ered. 2 

1 Richmond Med. Journ., Feb. 1886, from Confederate States Med. Journal. 

2 Ibid., January, 1866, p. 52. 



PART II. 



DISLOCATIONS. 



DISLOCATIONS. 



CHAPTEE I. 

GENERAL CONSIDERATIONS. 
§ 1. General Division and Nomenclature. 

A dislocation is the displacement of one bone from another at its 
place of natural articulation. 

Dislocations may be divided into accidental or traumatic, sponta- 
neous or pathologic, and congenital. 

Oar remarks upon the etiology, pathology, symptomatology, prog- 
nosis, and treatment of these injuries must be considered as applicable 
only to accidental or traumatic dislocations, unless the fact is in any 
case otherwise stated. 

Accidental dislocations are those in which the bones have suffered 
displacement in consequence of the application of a sudden force ; and 
surgeons have divided these accidents into Complete and Partial, 
Simple, Compound and Complicated, Eecent and Ancient, Primitive 
and Consecutive. 

A complete dislocation is one in which no portions of the articular 
surfaces remain in contact. 

A partial dislocation is one in which the articular surfaces are not 
completely removed from each other. 

A simple dislocation is that form of the accident in which the bone 
has only slid from its articulation, and is accompanied with the least 
or only an average amount of injury to the soft parts or to the bones 
adjacent to the joint. 

A compound dislocation implies that the articulating surface of the 
bone has been thrust through the flesh and skin, or that in some other 
way a wound has been made which communicates with the joint. 

Complicated dislocation is a term employed by some writers to 
designate a condition wholly differing from a compound dislocation, 
or, in some cases, a condition of extra complication. Thus, a simple 
dislocation may be complicated with a fracture, or with the laceration 
of an important bloodvessel, &c. ; and a compound dislocation may be 
complicated in the same way, and with the addition, perhaps, of exten- 
sive laceration and destruction of integument, muscles, nerves, &c. 

A recent luxation has taken place within a period of a few days, or, 



498 GENERAL CONSIDERATIONS. 

at most, of a few weeks ; and an ancient luxation has existed during 
a longer period. The exact point of time at which a dislocation shall 
be called recent or ancient is not fully determined by surgeons, and 
the application of these terms is therefore always somewhat arbitrary. 
A primitive luxation is a luxation in which the bone remains nearly 
or precisely in the position into which it was at first thrown ; while a 
secondary or consecutive luxation is one in which the bone has sub- 
sequently, in consequence of the action of the muscles, or from un- 
successful efforts at reduction, or from some other cause, changed its 
position sufficiently to entitle the accident to a new designation. Thus 
a primitive dislocation upon the ischiatic notch may become a second- 
ary dislocation upon the dorsum ilii, or the reverse. 



§ 2. General Predisposing Causes. 

Age. — According to Malgaigne, whose conclusions are based upon 
an analysis of six hundred and forty-three cases, dislocations are very 
rare in infancy, only one having occurred under five years ; but the 
frequency increases gradually up to the fifteenth year, from this period 
more rapidly up to the sixty-fifth year, and from this time onward 
again dislocations become more rare. He has mentioned none after 
the ninetieth year; and the period of greatest frequency is between 
the thirtieth and sixty-fifth year. To this middle period belong four 
hundred and seven of the whole number. 

The inference from this analysis may be thus briefly stated : age, as 
a predisposing cause, is most active in middle life, less active in ad- 
vanced life, and least active of all in early life. 

It is proper, however, to observe that while such statistics, may be 
relied upon as indicating the relative frequency of these accidents at 
different periods of life, they cannot be regarded as determining abso- 
lutely the value of age alone as a predisposing cause, since the direct 
or exciting causes may be more active at one period than another, and 
in some measure these latter causes may be, and doubtless are, respon- 
sible for such results. 

Constitution and Condition of the Muscles and Ligaments. — It may be 
stated as a general fact that persons of feeble constitutions, and whose 
muscular systems are much weakened, suffer dislocation from slighter 
causes than those who are in health, and whose muscular systems are 
firm and vigorous ; and that a relaxation of the ligaments which sur- 
round a joint, however this may have been occasioned, predisposes to 
dislocation. Thus, a paralyzed and atrophied limb is predisposed to 
luxation ; a joint in which the capsule has become stretched by effu- 
sions, or by violent extension, or weakened by laceration from a 
previous dislocation, or by ulceration, or if in any other way the 
articulation is deprived of these natural protections, we need scarcely 
say that it is thereby rendered more liable to luxation. 

Ball and socket joints, other things being equal, are more liable to 
displacement than ginglymoid ; but then much more depends upon 
the relative exposure of the joint than upon its anatomical structure, 



GENERAL SYMPTOMS. 499 

so that the elbow is much more frequently dislocated than the hip ; 
the shoulder -joint, however, being, from its position and extent of 
motion, peculiarly exposed, and being also a ball and socket joint, is, 
of all others, most liable to dislocation. 



§ 3. Direct or Exciting Causes. 

These may be classed under two general heads, namely, external 
violence and muscular action. 

External violence operates either directly or indirectly. When a 
person falls upon the knee and dislocates the head of the femur, the 
force is said to have acted indirectly, and this is by far the most 
frequent mode of dislocation ; but when the blow is received upon the 
upper end of the humerus, and its head is sent into the axilla, it is 
said to have been dislocated by direct violence. 

Muscular action produces a dislocation slowly, as in some cases of 
chronic rheumatism, and then it is called a spontaneous or pathologic 
dislocation; or suddenly, as in the violent spasmodic contractions 
which accompany convulsions ; or sometimes by the mere voluntary 
effort of the muscles ; and these latter are true accidental luxations. 

It is very probable that external force can seldom be regarded as 
the sole cause of a dislocation, but that, in a large majority of cases, 
muscular action consenting with the shock, performs an important 
role, in the history of the accident. The limb being driven obliquely 
across its socket by the external violence, is seized by the stretched 
and excited muscles with such vigor as to contribute not a little to 
the unfortunate result. Thus it will be found that the same force 
which is adequate to the production of a dislocation in the living and 
healthy subject is wholly insufficient to accomplish the same in the 
dead ; and a man who is fully intoxicated seldom suffers a dislocation. 



§ 4. General Symptoms. 

As fractures are characterized by preternatural mobility and crepi- 
tus, to which may be generally added the circumstance that, when 
reduced, the fragments will not remain in place without external 
support, so, on the other hand, dislocations are characterized by pre- 
ternatural rigidity, an absence of crepitus, and by the fact that, when 
reduced, the bone does not generally require support to maintain it 
in position. 

These three are the usual, and they may be termed the common, 
signs of distinction between fractures and dislocations, but no one of 
them can be alone depended upon as positively diagnostic. Generally, 
when a bone has been dislocated, we shall find the limb in a certain 
position, which is uniform for all dislocations of the same character, 
and almost immovably fixed ; but when the ligaments and muscles 
about the joint have been extensively torn, or the whole body is still 
suffering under the shock, or in any other circumstances where the 



500 GENERAL CONSIDERATIONS. 

power of the muscles is weakened, this rigidity may give place to 
extreme mobility. 

True crepitus does not exist without a fracture, but is not always 
present in fractures, and there is often a sensation produced in the 
rubbing and chafing of dislocated bones which very much resembles 
certain kinds of crepitus, and by the inexperienced has been often 
mistaken for it. I allude to the subdued rasping sound or sensation 
which is found generally on the second or third day, and sometimes 
earlier, and which is the result of fibrinous effusions, or, perhaps, in 
some instances, of the mere rubbing of firmly compressed ligamentous 
and cartilaginous surfaces upon each other. The crepitus of a recent 
fracture can be scarcely confounded with this obscure sensation, unless 
it is in some cases of incomplete fracture, or of a fracture situated 
remote from the surface, as in the case of the hip ; but a fracture 
which is a few days old, whose surface has become softened by in- 
flammation and more or less covered with lymph, and, when the 
rigidity is great, may sometimes deceive the most experienced sur- 
geon, so exactly will it be found to imitate the sensations produced 
by the chafing of an inflamed joint, or of closely approximated fibrous 
surfaces. 

I have said that a true crepitus does not exist without a fracture ; 
but then a very minute fracture, such as the detachment of a scale of 
bone by the tearing away of a tendon or of a ligament, may produce 
crepitus ; or even the separation of a piece of cartilage may sufficiently 
expose the bone to determine the presence of this phenomenon. These 
are, however, no longer examples of simple dislocation. 

Nor are the two inverse propositions, in relation to the retention of 
the bones in place, invariable in their application. A broken bone, 
well reduced, does not always manifest a tendency to displacement, 
nor does a dislocated limb, when restored to its socket, in all cases 
maintain its position without support. 

The other general signs of dislocation are pain, swelling, and dis- 
coloration. The pain is generally more intense in dislocations than 
in fractures, the expanded end of the bone resting often upon one or 
more large nerves, which usually, with the arteries, approach very 
near the joints, this pressure being also greatly increased by the 
extreme tension of the muscles. Not unfrequently numbness and 
temporary paralysis of the whole limb are the consequences. In 
other cases the pain is due solely to the pressure upon the muscles or 
to the tension of the muscles, or, perhaps, to the tension of the untorn 
ligaments and capsule. 

Generally the limb is shortened, but in a few cases it is found 
slightly lengthened, while the natural axis of the bone with its socket 
is always changed. If examined early, and before the supervention 
of swelling, the joint end of the displaced bone may be felt in its 
unnatural position, and a corresponding depression may be discovered 
in the situation of the articulation, especially if the bones are super- 
ficial. 



PATHOLOGY. 501 



§ 5. Pathology. 



The dissection of recent dislocations produced by external violence 
shows the capsular ligament more or less torn, and also a rupture of 
some of the lateral and other short ligaments, with a complete rupture 
in most cases of some of the tendons which immediately surround the 
joint, or of those which are attached to the capsule: the muscles, 
nerves, arteries, &c, through which the bone in its passage has passed, 
or upon which it is found resting, being also contused, stretched, or 
torn asunder. 

This description, however, does not apply to dislocations produced 
by muscular action alone, in a majority of which cases the capsule is 
only stretched, and not torn, and no lesions of other structures are 
necessarily present. 

If the dislocation remains unreduced, the margins of the old socket, 
in the case of enarthrodial articulations, become gradually depressed, 
while the concavity of the socket is filling in with a fibrous or bony 
tissue, until at length the whole of this portion of the joint apparatus 
is nearly or entirely obliterated. This process is generally very slow, 
and may not be consummated until after the lapse of many years. 

At the same time, but with much greater rapidity, the. head of the 
bone in its new position, and the soft or hard parts upon which it rests, 
are undergoing certain changes to adapt them to their new relations, 
and calculated in some measure to restore the limb to its normal func- 
tions. If the head of the bone rests upon muscle, the cellular and 
fibrous tissues which enter into the composition of the muscle become 
condensed and thickened, forming a shallow or elongated cup, whose 
margins are attached to the neck or shaft of the bone, and whose walls 
are lubricated with synovia. If it rests upon bone, by a process of 
interstitial absorption a true socket is formed, sometimes deep and 
sometimes shallow, whose edges, receiving additional ossific deposi- 
tions, become lifted so as to form a rim. At the same time the head 
of the bone is undergoing corresponding changes, to adapt itself to the 
newly-formed socket ; it is flattened or otherwise changed in form, and 
in the progress of this change its natural secreting and cartilaginous 
surfaces are gradually removed, a porcelaneous deposit taking its place. 
The same kind of hard, polished, ivory-like deposit is found also in 
those portions of the new socket which have been especially exposed 
to pressure and friction. Instead of the eburnation, an imperfect 
fibro-serous surface or synovial capsule may be formed. 

I have in my cabinet an example of ancient luxation of the hip-joint 
in which the head of the femur, having rested upon the dorsum ilii, has 
formed a nearly flat but smooth surface — a kind of elevated plateau ; 
in other cases I have seen the margins of the new socket so elevated 
as to rest against the neck of the femur, and completely lock it in. 

Consenting with these changes, and in consequence partly of the 
disuse of the limb, the muscles, and even the bones sometimes, suffer 
a gradual atrophy. In some measure these alterations may be due 
also to the pressure of the dislocated bone upon arterial and nervous 



502 GENERAL CONSIDERATIONS. 

trunks, by which their functions become partially or completely anni- 
hilated, and their structure even may be wholly obliterated. In conse- 
quence also of the inflammation which immediately results, we ought 
not to omit to notice that the large trunk of an artery sometimes 
becomes firmly adherent to the capsule or periosteum of a displaced 
bone, and its reduction is attended with imminent danger of laceration 
and of a fatal hemorrhage. Numerous instances of this grave accident, 
especially in attempts to reduce old dislocations of the shoulder-joint, 
are upon record. 

§ 6. General Prognosis. 

We shall study the prognosis of these accidents to better advantage 
when we come to speak of the individual bones and their various 
forms of dislocation ; but it is proper to state in this place, generally, 
that very few joints, having been once completely displaced from their 
sockets by external violence, are ever so completely restored as not to 
leave some traces of the accident for many years, if not for the whole 
of the subsequent life of the patient, either in the partial limitation of 
their motions, or in the diminished size and power of the muscles of 
the limbs, or in the presence of an occasional arthritic pain : the degree 
and permanence of these sequences depending upon the joint which is 
the subject of the displacement, the extent of the original injury, the 
length of time it has remained unreduced, the means employed in its 
reduction, the health and condition of the patient, with so many other 
contingent circumstances as to preclude the idea of a complete specifi- 
cation. 

If the bone is not reduced, a permanent maiming is inevitable ; but 
it is surprising how much time and the intelligent processes of nature 
can eventually accomplish toward a restoration of the natural func- 
tions, especially when aided by a good constitution and judicious 
treatment. If the symmetry of form and grace of motion are never 
replaced, the value of the limb, for all the practical purposes of life, 
is not unfrequently completely re-established. 



§ 7. General Treatment. 

The first indication of treatment is to reduce the bone. Whatever 
delays may be proper or justifiable in certain cases of fracture, such 
delays are never to be argued in cases of dislocation. The sooner the 
reduction is accomplished the better. For this purpose we resort at 
once to such manipulations or mechanical contrivances as the nature of 
the case demands ; and if these fail, or if at the first they are deemed 
insufficient, we invoke the aid of constitutional means, or such as are 
calculated to diminish the power and antagonism of the muscles. 

Many dislocations may be reduced promptly by manipulation alone; 
which mode is always to be preferred when it will prove sufficient, 
for the reasons that it is generally the least painful to the patient, and 



GENERAL TREATMENT. 503 

the least apt to inflict additional injury upon the muscles and liga- 
ments. 

A person wholly unacquainted with anatomy or surgery may occa- 
sionally succeed in reducing a dislocated limb ; indeed, it frequently 
happens that the patient himself, by mere accident in getting up or 
in lying down, accomplishes the reduction ; and even in a very large 
majority of cases force and perseverance will finally succeed by whom- 
soever they may be employed; but the observing student of surgery 
will soon discover the difference between accident and brute force on 
the one hand, and intelligent manipulation on the other. The char- 
latan bone-setter does not often allow himself to fail, unless the cou- 
rage of his patient gives out, or he ignorantly supposes the reduction 
to be effected when it is not ; but his success, achieved through great 
and unnecessary suffering, is often obtained, also, at the expense of 
the limb. While the surgeon, whose knowledge of anatomy enables 
him to understand in what direction the muscles are offering resist- 
ance, and through what ligaments the head of the bone must be 
guided, lifts the limb gently in his hands, and the bone seeks its 
socket promptly and without disturbance, as if it needed only the 
opportunity that it might demonstrate its willingness to return. 

We must understand not only what muscles and ligaments antag- 
onize the reduction, if we would be most successful, but also what 
muscles, by being provoked to contraction, will themselves aid in the 
reduction. In short, to become expert bone-setters in the department 
of dislocations, one must possess a complete knowledge of the phy- 
siognomy or the external aspect of joints, acquired only by repeated 
and careful examinations, he must be familiar with the anatomy and 
functions of the muscles, he must understand thoroughly the ligaments, 
he must have experience, tact, and fertility of resource. 

Without these qualifications a man will do better never to under- 
take to treat dislocations, since he is constantly liable to mistake frac- 
tures for dislocations, and dislocations for fractures; he will submit a 
sprained wrist to violent extensions under the conviction that the 
joint is displaced ; he will mistake natural projections for deformities, 
and fail to recognize the real deformity when it actually exists ; he 
will leave bones unreduced, fully believing that they are reduced ; and 
he will, all in all, within a few years, accomplish vastly more evil than 
he can ever do good. Let a man practise any other branch of surgery 
if he will, without experience or scientific knowledge, but he must 
not attempt to reduce dislocated bones. The most learned and the 
most skilful we shall find falling into error, embarrassed by the un- 
certainty of the diagnosis, or successfully resisted by the power of the 
opposing agents ; what then can be expected of those who are both 
ignorant and inexperienced, but failures and disasters ? 

As a means of disarming the muscles, or of placing them off their 
guard, we often practise successfully the diversion of the mind of the 
patient. At the very moment that the limb is moved or extension is 
made, a question is addressed to him, or he may be suddenly surprised 
by some unexpected intelligence. 

Extension and counter-extension, made with our own hands or with 



50-i 



GENERAL CONSIDERATION'S, 



Fie. 214. 



the hands of assistants, constitute the second resort where manipula- 
tion alone has failed. The surgeon, seizing upon the limb firmly with 
his hands, makes the extension, while the assistants make the counter- 
extension ; or, instead of grasping the limb directly, the operator may 
use for this purpose circular and longitudinal 
bandages, or the bandage or handkerchief tied 
in the form of the clove hitch. Extension is 
thus applied in connection with manipula- 
tion, aided, perhaps, by direct pressure upon 
the head of the displaced bone. Failing in 
this, we employ some one of the various 
mechanical contrivances which, while they 
are capable of exerting much more power, 
possess also the important advantage of 
operating gradually and steadily, by which 
mode the resistance of the muscles is always 
more speedily and more completely over- 
come. 

For this purpose surgeons employ generally 
in the case of the large limbs the compound 
pulleys or the simple rope windlass, which is 
thus described by Dr. Gilbert, of Philadel- 
phia: "Place the patient, and adjust the ex- 
tending and counter-ex tending bands as for the 
pulleys ; then procure an ordinary bed-cord 
or a wash-line, tie the ends together and again 
double it upon itself, pass it through the ex- 
tending tapes or towels, doubling the whole once more, and fasten the 
distal end, consisting of four loops of rope, to a window-sill, door-sill, 
or staple, so that the cords are drawn moderately tight ; finally, pass a 




Clove hitch. (From Erichsen.) 



Fig. 215. 





Compound pulleys and ring to trhich one end of the pulley rope is fastened. 



stick through the centre of the double rope, then by revolving the stick 
as an axis or double lever, the power is produced precisely as it should 
be in such cases, viz., slowly, steadily, and continuously." 

Jarvis's adjuster, although very complex, possesses some advantages 



DOUBLE OR BILATERAL DISLOCATION. 505 

over the pulleys, which may, perhaps, entitle it to the preference in a 
few cases. 

Among the constitutional means, ether and chloroform occupy the 
first rank ; indeed they are, at the present day, almost the only means 
of this class to which surgeons resort, and their value in this point 
of view can scarcely be overestimated. Only when some unusual 
circumstance or condition of the patient forbade the use of an anaes- 
thetic, would the surgeon return to the ancient practice of bleeding 
ad deliquium, of prostrating the system with antimony, or to the use 
of those vastly less efficient agents, opium and the warm bath. 



CHAPTEE II. 

DISLOCATIONS OF THE LOWER JAW. 

There are two principal forms of this dislocation, namely, the 
double or bilateral dislocation, and the single or unilateral ; in both 
of which the direction of the displacement is forwards. To these 
there has been added one example of an outward displacement 
accompanied with a fracture. 1 

§ 1. Double or Bilateral Dislocations. 

This form of dislocation of the lower jaw is much the most frequent, 
being met with in about two out of every three cases. It appears also 
to occur oftener in women than in men, and usually between the twen- 
tieth and thirtieth year of life. In infancy and extreme old age it is 
exceedingly rare ; yet Sir Astley Cooper mentions a case in which 
" two boys" being at play, one had an apple thrust into his mouth, 
producing a double dislocation ; and Nelaton saw the same accident 
in an old man of seventy-two years, who was toothless. 

This comparative immunity in youth and old age has been ascribed 
to certain peculiarities in the form of the jaw at these periods of life. 
Nekton attributes its more frequent occurrence in middle life to the 
great length and strong anterior inclination of the coronoid process. 

In a majority of cases the direct or immediate cause has seemed to 
be muscular action alone. Malgaigne found this cause to prevail in 
twenty-five out of forty cases ; and of the twenty-five cases fifteen 
were occasioned by gaping, five by convulsions, four by vomiting, and 
one by rage. Dr. Physick, of Philadelphia, found both condyles dis- 
located in a woman in consequence of the violent gesticulation of her 
jaw while scolding her husband. But in a more remarkable case still, 
this surgeon found the jaw dislocated after recovery from a profuse 

1 Robert, Journal de Chir., 1844. 

33 



506 DISLOCATIONS OF THE LOWER JAW. 

salivation, and of the cause of which, or the time of its occurrence, 
the patient, a young girl, could give no account. Dr. Physick made 
several ineffectual attempts at reduction, and only succeeded at last 
after he had made her completely intoxicated with ardent spirits. 1 

Dr. E. Andrews, of Michigan, found both condyles dislocated by a 
lobelia emetic. The patient had often taken these emetics before, and 
had frequently experienced a sensation "of catching" at the joint, but 
the jaw had always until this time resumed its position spontaneously. 2 

Among the causes from outward violence, the introduction of some 
foreign body into the mouth, and the extraction of teeth, occupy the 
most important place. In fifteen cases, seven were from the former 
and six from the latter cause. 

My late pupil, A. W. Gilbert, has related a case which came under 
his own observation, produced by a similar cause. During his appren- 
ticeship with Dr. Parsons, a dentist, he was requested to insert a set of 
teeth for a young man residing in Cattaraugus Co., N". Y., and while 
opening his mouth to take an impression of his gums, he dislocated 
"both condyles forwards, under the zygomatic arches;" but so perfectly 
were the muscles relaxed, that he immediately reduced them, without 
the least difficulty, by placing his thumbs as far back as possible upon 
the molar teeth, depressing the back part of the jaw, and at the same 
moment elevating the chin. 3 

The late Prof. James Webster, of Eochester, N. Y., dislocated the 
jaw of a lady while attempting to pry out a root of one of the molars. 

Pathology. — In order that we may better understand the pathology 
of this accident, it will be proper to say a few words in relation to the 
anatomy of the temporo-maxillary articulation and the other parts 
concerned in the dislocation now under consideration. 

The articulation is formed by the condyloid process of the inferior 
maxilla and the glenoid fossa of the temporal bone, in front of which 
fossa, and at the root of the zygomatic arch, is a slight elevation, called 
the articular eminence. Between the joint surfaces, both of which are 
covered with cartilage of incrustation, is placed an interarticular car- 
tilage, which divides the joint into two cavities, one corresponding to 
the condyle of the inferior maxilla, and the other to the glenoid fossa, 
each of which is furnished with a distinct synovial membrane. 

Properly there is but one ligament — namely, the external lateral — 
which passes from the outer surface of the articular eminence to the 
corresponding surface of the neck of the condyle. What is called the 
internal lateral ligament arises from the apex of the spinous process of 
the sphenoid bone, and is inserted into the margin of the dental fora- 
men, and has therefore no immediate connection with the articulation, 
although it tends to strengthen the joint. The same is true of the 
stylo-maxillary ligaments. 

The lower jaw is drawn upwards, or closed upon the upper jaw by 
the action of. the temporal, masseter, and internal pterygoid muscles ; 

1 Physick, Dorsey's Elements of Surgery, vol. i. p. 202. Philadelphia, 1813. 

2 Andrews, Peninsular Jour. Med., vol. iii. p. 101. 1855. 

3 Gilbert, Thesis on Dislocation of the Inf. Max. University of Buffalo, 1858. 



DOUBLE OR BILATERAL DISLOCATION. 



507 



it is drawn downwards by the action of the digastricus, mylo-hyoideus, 
and genio-hyoglossus muscles ; forwards by a few fibres of the masseter 
and by the external pterygoid muscles ; and laterally by the alternate 
action of the external and internal pterygoid muscles. 

When the mouth is open to its utmost extent, the maxillary condyle 
rises upon the articular eminence until it rests upon its very summit. 
Indeed, it is probable that in most persons it advances rather in front 
of the centre of the eminence; so that in order to become actually dis- 
located it only needs that the capsule shall be somewhat relaxed, or 
that it shall actually give way in front, when the condyles slide for- 
wards and occupy a position directly in front instead of behind this 
eminence. 

It is easy to comprehend how the combined action of the two ex- 
ternal pterygoid muscles, with a portion of the fibres of the masseter, 
may alone produce the dislocation when the mouth is wide open, and 
especially when, in consequence of a slight blow upon the chin, the an- 
terior portion of the capsule becomes lacerated; for it must be noticed 
that the ascending ramus, with its 

prolonged condyloid process, con- Fig- 216. 

stitutes a lever of the first kind, 
in which the temporal muscle, 
attached to the coronoid process, 
the masseter, and even the mas- 
toid process, constitute the ful- 
crum, the anterior portion of the 
capsule, the weight, and the force 
acting against the front of the 
chin, the power. 

In this position of the condyle, 
drawn upwards and forwards by 
the action of the pterygoid and 
temporal muscles, the chin de- 
scends toward the neck, and the 
coronoid process rests against the back of the superior maxilla, or 
against the malar bone at the point of its junction with the upper 
maxillary. The temporal, masseter, and internal pterygoid muscles 
are very much upon the stretch, if not more or less lacerated. 

Symptoms. — The mouth is widely open and the jaw nearly immov- 
able. It has been noticed generally that, by pressure, the chin may be 
slightly depressed, but that, owing probably to the pressure of the coro- 
noid process against the body of the upper maxilla, or against the 
malar bone, it is generally impossible to elevate the jaw in any degree 
whatever. 

The jaw is also slightly advanced; a depression, covering a con- 
siderable space, exists between the auditory canal and the posterior 
margin of the condyle. A slight fulness is observed in the temporal 
fossa and also upon the side of the cheek in the region of the masseter 
muscle. 

Ordinarily the patient suffers considerable pain, but not always, from 
the pressure of the condyles upon the branches of the temporal nerves. 




Double dislocation of the inferior maxilla. 



508 



DISLOCATIONS OF THE LOWER JAW. 



Fig. 217. 



There is a constant flowing of the saliva from the mouth ; the patient 
is unable to articulate, and even deglutition is performed with great 
difficulty. 

Prognosis. — When the dislocation remains unreduced, the lower jaw 
gradually approximates the upper, and its anterior projection sensibly 

diminishes, the saliva ceases to drib- 
ble from the mouth, deglutition and 
speech are restored, mastication is 
performed with considerable ease, 
and, in short, the patient comes at 
length to experience no great incon- 
venience from the displacement. 

Robert Smith relates the case of a 
woman whose lower jaw was dislo- 
cated during an epileptic convulsion. 
She was at the time in one of the 
metropolitan hospitals, but the acci- 
dent was not noticed by the surgeons, 
and it remained ever afterwards un- 
reduced. At the end of a year she 
could close the lips perfectly, but was 
able to open the mouth only to a 
limited extent ; the teeth of the lower 
jaw remained advanced, the involun- 
tary flow of saliva had ceased, and 
the faculty of speech had been re- 
gained. 1 In Professor Webster's case, 
to which I have before referred, 
although the jaw was immediately and easily reduced, after the lapse 
of several years, when I saw the lady, she still complained that it hurt 
her whenever she ate, and that she often felt the condyles slip in their 
sockets. 

Reduction has been accomplished by Physick in the case already 
related after the lapse of several weeks ; Sir Astley reduced a double 
dislocation after one month and five days, which had been overlooked 
by the surgeon in attendance ; 2 and Donovan succeeded after ninety- 
eight days. 3 

Treatment. — Reduction may generally be accomplished with ease in 
cases of recent luxation, in the following manner : The patient being 
seated upon the floor- with his head between the knees of the operator, 
a couple of pieces of cork, gutta percha, or pine wood are placed as 
far back between the molars as possible, when the surgeon seizing 
upon the chin draws it steadily upwards, taking care not to draw it 
forwards at the same time, since by this movement he would resist 
the action of the muscles which naturally tend to restore it to place 
whenever the condyloid processes are lifted sufficiently from the 




Double dislocation of the inferior maxilla 



1 Robert Smith, on Fractures and Dislocations. Dublin, 1854, p.. 288. 

2 Sir Astley Cooper, on Disloc. and Frac, Amer. ed., p. 316. 

3 Donovan, Amer. Journ. Med. Sci., Oct. 1842, p. 470, from Dublin Med. Press, 
May 25, 1842. 



SINGLE OE UNILATERAL DISLOCATIONS. 509 

zygomatic fossa?. Many surgeons prefer to sit or stand in front of 
the patient, and depress the condyles by means of the thumbs placed 
inside of the mouth and upon the tops of the molars. If the thumbs 
are used in this way, it would be well to protect them with a piece of 
leather, or to slip them off from the teeth suddenly when the condyles 
are gliding into their places, as the muscles sometimes close the mouth 
with sufficient violence to bruise severely anything which might at 
this moment be interposed between the teeth. 

The method practised by Eavaton, of simply lifting the chin gradu- 
ally and forcibly toward the upper jaw, was essentially the same, but 
far less efficient ; for although he placed nothing between the molars 
to serve as a fulcrum, the backmost teeth themselves must in some 
degree perform this service whenever the lower jaw being dislocated 
and drawn upwards, the chin is forcibly approximated toward the 
upper. 

In other cases it has been found necessary first to disengage the 
coronoid process, by depressing the chin gently, and then pressing 
backwards in the direction of the articulation; a method which would 
certainly deserve a trial in case of the failure of that first described. 
This was the method practised by Hippocrates. 

A more effectual expedient, however, consists in reducing one side 
at a time; taking good care always that the side first reduced is not 
reluxated while the attempt is being made to reduce the other, a 
thing which happened in one of the cases treated by Sir Astley 
Cooper, and has happened many times in the practice of other sur- 
geons. 

Finally, if all other expedients fail, we ought not to hesitate to 
resort to anaesthetics, nor indeed could any objection exist to their 
employment at any period of the treatment, were it not that in a large 
majority of cases the reduction is effected so easily and promptly as 
to render their employment wholly ud necessary. 

After the reduction is accomplished, it will be a matter of wise pre- 
caution to sustain the jaw by a double-headed bandage passed under 
the chin, and secured upon the top of the head, so as to prevent the 
mouth from being accidentally opened too far, especially during sleep, 
since experience has shown that a tendency to a reproduction of the 
dislocation remains for some time. It will be prudent to continue 
these measures of protection for at least one week ; after which the 
danger of anchylosis should be borne in mind, and the extent of 
passive motion should be gradually and cautiously increased. In 
illustration of this tendency to reluxation, Malgaigne refers to the 
case mentioned by Putegnat of a woman whose jaw for many years 
became luxated at least once a month ; but she was always able to 
reduce it herself. 



§ 2. Single or Unilateral Dislocations. 

The causes of this accident are in general the same as those which 
produce double dislocations, and it occurs most often in middle life. 



510 DISLOCATIONS OF THE LOWER JAW. 

Tartra has seen one exceptional example in a child only fifteen 
months old ; and Levison saw a case in an old man who had lost all 
his teeth. 1 

Symptoms. — The mouth is open, hut not so widely as in double dis- 
location ; the jaw is nearly immovable; the teeth are advanced; the 
condyloid process can be felt in front of the articular eminence, leav- 
ing a depression in its natural situation, and the coronoid process is 
more prominent than in the bilateral dislocation. 

It will be remembered that we have already pointed out an import- 
ant diagnostic mark between a fracture of the neck of the condyloid 
process and a dislocation of one condyle. . In the latter the chin in- 
clines to the opposite side, while in the former it falls toward the side 
upon which the accident has occurred. According to Hey, this lateral 
deviation of the chin is not always present in dislocations ; and Eobert 
Smith mentions one case in which the surgeon was misled by this 
circumstance so far as to attempt a reduction upon the left side when 
the dislocation was upon the right. 

Treatment. — The same rules of treatment which we have established 
for dislocations of both condyles will be applicable to the single dislo- 
cations, with only such modifications as will be naturally suggested to 
the surgeon. 

In the case mentioned by Levison, the dislocation was constantly 
recurring upon the left side ; and it was especially liable to happen 
when just awakening from sleep. " He would then pull his jaw, press 
it backwards, when, after about half an hour's work, bang it seemed 
to go, and all was right again." This old gentleman was finally 
relieved of these annoyances by a band fastened under the chin. In 
such a case, an apparatus constructed after the same plan as my lower 
jaw fracture apparatus might perhaps serve a useful purpose. 



§ 3. Conditions of the Jaw simulating Luxations. 

There is a condition of the temporo-maxillary articulation called by 
Sir Astley Cooper "subluxation of the jaw," in which it is assumed 
that the condyles slip before the anterior margins of the interarticular 
cartilages, and thus for the time render the jaw immovable. No posi- 
tive evidence, however, has ever been presented, either by Sir Astley 
or others, that any such derangement of the joint apparatus does actu- 
ally take place, the opinion being based, not upon dissections, but 
only upon the symptoms which are known to accompany the accident. 
It is quite probable that this explanation of the phenomenon in ques- 
tion is the true one, yet it is not impossible that it has no relation 
whatever to the interarticular cartilages, but that it indicates a true 
subluxation of the inferior maxilla upon the zygomatic eminences. 

It occurs mostly in young people, and in those of a feeble or scro- 
fulous diathesis. Kelaxation of the capsule, ligaments, and muscles 

1 Levison, Boston Med. and Surg. Journ., vol. xxxiv., 1846, p. 388, from London 
Lancet. 



CONDITIONS OF THE JAW SIMULATING LUXATIONS. 511 

about the joint may, therefore, be regarded as the principal predispos- 
ing causes. The exciting causes are generally yawning, or biting upon 
some very hard substance. 

The symptoms are a sudden arrest of the motions of the jaw, with 
the mouth about half open, the arrest of motion being accompanied or 
preceded generally with a sensation of slipping in one of the articula- 
tions. The chin is slightly inclined to the opposite side. The condyle 
may be felt somewhat advanced in its socket, and while it remains in 
this position the patient experiences some pain. 

Frequently the condyle resumes its place spontaneously, or after a 
slight lateral motion of the jaw ; but at other times it requires some 
little manual force to replace it. 

I have myself, during several years of my early life, while pursuing 
my studies at college, experienced this accident many times. It was 
peculiarly prone to occur in the morning, and it became necessary 
that I should eat with some care at my first meal. Sometimes the 
locking of the jaw was upon the right and sometimes upon the left 
side; it was always painful. Generally the condyle was made to fall 
into place by a voluntary lateral motion of the jaw, but occasionally I 
was obliged to press gently against the chin with my hand.- I never 
adopted any measures to remove the predisposition, but as I became 
older the annoyance gradually ceased. 

Benevoli, in a dissertation published at Florence, Italy, in the year 
1747, describes another condition very analogous to this which we 
have now described, but which evidently depended upon a contraction 
of the muscles. A priest having opened his mouth very widely in 
gaping, found himself unable to close it. A surgeon who was called 
diagnosticated a dislocation of the jaw, and attempted to reduce it, but 
failing, Benevoli was called, who, observing "that the jaw was not 
absolutely immovable, that the articulations were not separated, and 
that the chin did not incline outwards or toward the sternum," con- 
cluded that it was only a contraction of the depressing muscles. He 
therefore prescribed fomentations and oily unctions. The same night 
the temporal muscles had acquired the size of a couple of eggs, from 
contraction, but the next day the patient could shut his mouth, and 
by the following day the tumefaction of the temporal muscles had also 
disappeared, and the restoration of the functions of the mouth was 
complete. 

Malgaigne, to whom I am indebted for the above case, relates two 
others, one in the person of the surgeon Mothe, and the other in a 
young man who was suffering from paralysis and spasmodic contrac- 
tions of the muscles. Mothe observes that it had occurred to him 
very often, and that it still continued to happen sometimes, that when 
he gaped pretty widely, the genio-hyoid and mylo-hyoid muscles con- 
tracted with so much force as to render it impossible for him to close 
his mouth ; these muscles being thus in a state of cramp, their bellies 
became hard under the chin, and so painful that he was obliged imme- 
diately to press upwards against the under surface of the chin in order 
to oppose their action. This condition would last from one to three 



512 DISLOCATIONS OF THE SPINE. 

minutes, and was relieved, generally, by frictions made with the hand 
over the contracted muscles. Sometimes he actually believed that 
the lower jaw was dislocated, although the result always convinced 
him that it was not. 



CHAPTEE III. 

DISLOCATIONS OF THE SPINE. 

Delpech and Abernethy denied the possibility of a dislocation of 
the spine, either in the cervical, dorsal, or lumbar region, without the 
concurrence of a fracture. 

Says Sir Astley Cooper : u I have never witnessed a separation of 
one vertebra from another through the intervertebral substance, with- 
out fracture of the articular processes ; or, if those processes remain 
unbroken, without a fracture through the bodies of the vertebrae." 
He would not, however, be understood to deny the possibility of a 
dislocation of the cervical vertebrae, their articular processes being 
placed more obliquely than those of the other vertebras. 

The accident is, no doubt, exceedingly rare, at least without the 
complication of a fracture, and it is not improbable that the actual 
number is smaller than the reported examples would indicate. Those 
who make autopsies do not always perform their duties with that 
exact fidelity which might be necessary to determine so nice a point 
as a fracture of an oblique process, and it is quite likely that the cir- 
cumstance may have been overlooked in some cases ; but a consider- 
able number of well-authenticated examples of simple dislocations of 
cervical vertebrae have accumulated within the last fifty years. The 
reported examples of simple dislocations of the other vertebras are not 
so numerous, nor as well attested. 

The causes are in general the same with those which produce frac- 
tures of the vertebrae, such as falls upon the head, feet, or back, and 
violent flexions of the spine backwards or to the one side or the other. 

Several examples are recorded of "spontaneous" dislocations, the 
result of some morbid changes in the bones or in the ligaments of the 
spinal column; which accidents seem to belong more properly to 
general treatises upon surgery. 

The symptoms, also, partake of the same general character with 
fractures ; the accident being accompanied with more or less complete 
paralysis of those portions of the body which receive their nervous 
supply from below the point at which the dislocation has occurred ; 
the spinal column presenting at the seat of displacement an angular 
projection or some form of irregularity ; and the distortion being 
attended with pain, especially when an attempt is made to move the 
body. 

In very many cases the symptoms are so nearly like those presented 



DISLOCATIONS OF THE LOWES VESTEBSJ. 513 

in a case of fracture, that the diagnosis is rendered exceedingly difficult. 
The presence or absence of crepitus may aid in the diagnosis, and yet 
it is well understood that this symptom is often absent in simple frac- 
tures, and that it may be present in all those examples of dislocation 
which are accompanied with a fracture of an oblique process, or of 
any other portion of the vertebrae, which class of examples constitutes 
a large majority of the whole number. 

There is usually present, however, in the dislocation, whether partial 
or complete, a peculiar fixedness or rigidity of the spine, which serves 
to distinguish this accident from a fracture of the spine as plainly as 
the preternatural rigidity of the limb in dislocations of the long bones, 
serves to distinguish these accidents from fractures of the same bones. 
The head or upper portion of the spinal column is bent forwards, or 
backwards, or more commonly to one side, and in this position it 
remains immovably fixed until the reduction is accomplished. Some- 
times, also, the surgeon may feel distinctly the lateral deviation of 
the spinous process, and, in the neck, the transverse processes become 
an important guide in the diagnosis. 

After these few general remarks, I shall proceed to speak of disloca- 
tions of the spine in the same order in which I have treated of fractures 
of the spine. 



§ 1. Dislocations of the Lumbar Vertebra. 

Sir Astley Cooper plainly intimates that he does not believe a dis- 
location can occur in either the dorsal or lumbar region without the 
concurrence of a fracture, and Boyer affirms positively that it is 
" entirely impossible." 

Without wishing ourselves to insist upon the actual impossibility 
of these accidents, we are prepared to affirm that no well-authenticated 
case has yet been reported ; at least of a complete dislocation, unac- 
companied with a fracture of the articulating apophyses. We can 
even conceive it possible that a lumbar vertebra may be dislocated 
forwards or backwards, and that a dorsal vertebra may be dislocated 
laterally without a fracture ; yet we hardly think either of these events 
probable. What we urge, however, is that no evidence appears to be 
furnished that such a dislocation has actually occurred. 

Cloquet mentions the case of a " tiler" who fell from the roof of a 
house backwards, and dislocated one of the lumbar vertebrae. This 
patient lived many years after the accident, and at the autopsy it was 
found that the second lumbar vertebra had been luxated to the ri^ht 
by a movement of rotation about the left articular process, the two 
oblique processes of the left side preserving their connection, while 
those of the right were separated quite half an inch. The right verte- 
bral plate was broken, and the canal of the vertebra was thus thrown 
open and widened. 1 

Dupuytren says that a man was crushed by the falling of a bank of 

1 Cloquet, Malgaigne, from Journ. des Difformites de Maisonabe, torn. i. p. 453. 



514 DISLOCATIONS OF THE SPINE. 

earth upon his loins, when in the act of bending forwards. On the 
third day he was brought to Hotel Dieu, when it was observed that 
his lower extremities were completely paralyzed ; and that there 
existed in the upper part of the lumbar region a hard tumor ; by pres- 
sure upon which a crepitus was manifest. A second tumor could be 
distinctly felt in front through the abdominal parietes, and the length of 
the spine was evidently diminished. This man died on the sixth day 
from a gradual asphyxia. When the body was examined it was found 
that the last dorsal and first lumbar vertebras had been pushed for- 
wards more than one inch, lacerating the spinal marrow, breaking the 
transverse and oblique processes of the last dorsal and first two lum- 
bar vertebras, and tearing off a small fragment of the body of one of 
the vertebras where the intervertebral substance adhered to it. 1 

These are all the cases of dislocation of the lumbar vertebras of 
which I am able to find any record. Both were accompanied with 
fractures. In neither case was any attempt made to reduce the dis- 
locations. In the second, it is scarcely probable that any means could 
have been employed which would have succeeded in restoring the 
bones to their places ; nor is it probable that if the bones had been 
restored to place, the patient would have survived the accident a 
day longer, probably not so long. The cord was greatly lacerated, 
and the diaphragm torn up and displaced, rendering a recovery almost 
impossible. 

In the first example, where the dislocation was less complete, and the 
complications less grave, could reduction have offered any reasonable 
chance for relief? By extension, combined with a movement of rota- 
tion in a direction opposite to that in which the displacement had 
taken place, it is possible that a reduction might have been accom- 
plished. The attempt certainly would have been justifiable; but since 
the man lived "many years" without the reduction, it is doubtful 
whether the result of a reduction would have been more fortunate. 



§ 2. Dislocations or the Dorsal Vertebra. 

Malgaigne enumerates twelve examples of dislocations of the dorsal 
vertebras. I have found reported by American surgeons, at dates too 
recent to have been included in his analysis, two other examples ; but 
of this number only three are claimed to have been simple dislocations, 
unaccompanied with fracture. One of the fourteen was a dislocation 
of the fifth dorsal vertebra upon the sixth, one of the eighth, two of the 
ninth, five of the eleventh, and five of the twelfth. The relative fre- 
quency of their occurrence in the different vertebras corresponding 
with the observation of Weber, as to the points of the spinal marrow 
which allow of the greatest freedom of motion, and are consequently 
most liable to dislocations. The direction of the displacement in ten 
cases was observed to be six times forwards, twice backwards, and 
twice to the one side. 

1 Dupuytren, Injuries and Dis. of Bones, Syd. ed., p. 340. 



DISLOCATIONS OF THE DOESAL VEETEBEJI. 515 

Two of those which were unaccompanied with fracture, occurring 
respectively in the tenth and sixth dorsal vertebrae, were examples of 
a dislocation forwards, and the third, belonging to the ninth vertebra, 
was a dislocation backwards. A lateral luxation without fracture has 
not been recorded. It is worthy of remark, also, that these three 
examples, being all which our science up to this moment possesses, 
have happened in the experience of the same surgeon. 1 

A moment's consideration of the anatomy of these processes will 
render it apparent that even a partial luxation forwards without a frac- 
ture of the oblique apophyses is impossible, and that in the direction 
backwards the luxation can only occur to the extent of about one- 
quarter of an inch, constituting only a species of articular diastasis, 
without breaking off the articulating apophyses of the lower corre- 
sponding vertebra. The first two examples, therefore, notwithstanding 
they have been received without question by Malgaigne, I shall un- 
hesitatingly reject. The third, which alone carries evidence of its 
having been correctly reported, and which was only a partial disloca- 
tion, is related as follows: "A mason having fallen from a height in 
such a manner as that the lower part of his back struck upon the 
angle of the upper step of a ladder, died on the following day. After 
death it was observed that the spinous processes of the dorsal vertebrae 
were prominent down to the tenth ; and that the tenth process with all 
of the processes below were depressed. It was also noticed that this 
depression, very marked when the trunk was thrown backwards, 
gradually diminished and finally disappeared altogether when the 
body was bent forwards. On removing the soft parts it w r as found 
that the ligaments were extensively torn asunder and detached, so as 
to permit the articulating apophyses of the tenth vertebra to be carried 
into contact with the back of the ninth. The spinal marrow had un- 
dergone no visible alteration." 2 

Malgaigne thinks he has once observed the same thing on a living 
subject, and that by simply bending the body forwards he accom- 
plished the reduction and effected a perfect cure, except that a slight 
curvature remained at the point of injury. 

Among the cases reported as having been complicated with fracture, 
the following example, reported by Dr. Graves, of New Hampshire, to 
Dr. Parker, of this city, possesses unusual interest. 

On the second day of Jan., 1852^ a man, aet. 25, was struck on the 
back while in a stooping posture by a falling mass of timber, causing 
a dislocation of the last dorsal upon the first lumbar vertebra. His 
lower extremities were completely paralyzed, and priapism continued 
for several hours. The surgeon determined to make an attempt at re- 
duction, and for this purpose he placed the patient upon his face, and 
secured a folded sheet under his armpits and another around his hips, 
directing four strong men to make extension and counter-extension by 
these sheets. Chloroform was administered, and when the patient was 
completely under its influence the extending and counter-extending 
forces were applied, and in a few minutes the vertebrae glided into 

1 Melcbiori, Gaz. Medica, stati sardi, 1850. 2 Melcliiori, loc. cit. 



516 DISLOCATIONS OF THE SPINE. 

place with a distinct bony crepitus. The restoration of the line of 
the vertebral column was found to be nearly but not quite perfect. 

On the sixteenth day he began to have slight sensations in his feet, 
and at the end of six or eight weeks he was able to control the evac- 
uations from the bladder and rectum. Several months later he had 
recovered so completely as to walk with only the aid of a cane. 1 

I know of only one similar case. Eudiger has published an account 
of a dislocation obliquely backwards and to the right side, which 
occurred at the same point in the spinal column. The subject was a 
musketeer, who had been struck upon his back by a falling wall 
which he was endeavoring to pull down. Eudiger laid him upon his 
belly, and by the assistance of others he was able, but not without 
causing pain, to reduce the bones. Immediately, however, when the 
extension was discontinued, the action of the muscles caused the dis- 
placement to recur. The surgeon then directed four men to make 
extension, while another man retained the bones in place by pressing 
upon them with his hands. After several hours this method of pres- 
sure was replaced by a board underlaid with compresses and sustain- 
ing a weight of more than fifty livres. On the following day it was 
found' sufficient to bind compresses over the projecting bone, and in 
this condition the patient remained fifteen days ; during all of which 
time he lay upon his belly with his shoulders more elevated than his 
pelvis. On the twentieth day he could lie upon his back, and in 
about six weeks he was so completely restored as to be able to pursue 
his trade as before! 2 This is certainly a very extraordinary case, 
whether considered in reference to the means employed to restore the 
bones to place, or to its results : and if the statements are to be re- 
ceived at all, it must be with some hesitation and allowance. 

On the other hand, we are able to present at least one example in 
which, although no reduction has been accomplished, the patient has 
survived the accident many years ; yet it must be admitted that his 
recovery is far from having been as complete as in the two cases just 
mentioned. 

Joseph Stocks, set. 11, in the spring of 1826, was crushed under the 
body of an ox-cart in such a manner as to produce a dislocation of 
the last dorsal from the first lumbar vertebra, causing immediately 
almost complete paralysis of all the parts below. This young man 
was seen by Dr. Swan, of Springfield, Mass., in the summer of 1834, at 
which time he was occupied as a portrait painter. His lower extremi- 
ties remained paralyzed and of the same size as at the time of the 
receipt of the injury. He was unable to sit erect owing to the mobility 
of the spine at the seat of dislocation, and he had therefore lain con- 
stantly upon his side. The upper portion of his body was well de- 
veloped, and his intellectual faculties were of a high order. 3 

It is not, however, with a life of perpetual deformity that the two 
examples of reduction already described are to be contrasted. A result 

1 Graves, N. Y. Journ. Med., March, 1852, p. 190. 

2 Rudiger, Journ. de Chir. de Desault, torn. iii. p. 59. 

3 Swan, Bost. Med. and Surg. Journ., vol. xxii. p. 102, March 1S40. 



DISLOCATIONS OF SIX LOWEE CERVICAL VERTEBRAE. 517 

so fortunate as this, where the bones remain unreduced, is unique, in 
all the other cases reported the patients died miserably after periods 
ranging from a few days to one year or a little more. 

Charles Bell has related the case of an infant who was run over 
by a diligence, and who died thirteen months after the accident. On 
examination after death the last dorsal vertebra was found to be com- 
pletely luxated backwards and to the left, upon the first lumbar 
vertebra. 1 

With these facts before us, I think we cannot hesitate, when the 
nature of the accident is fully made out, and especially when the dis- 
location has occurred in the lower dorsal vertebrae, to attempt the 
reduction by forcible extension, united with judicious lateral motion, 
or with a certain amount of direct pressure upon the projecting 
spines. 

§ 3. Dislocations of the Six Lower Cervical Vertebra. 

It is much more common to meet with simple luxations of the ver- 
tebra? of the neck uncomplicated with fractures, than of either of the 
other vertebral divisions. This is doubtless owing to the greater 
extent of motion which their articulating surfaces enjoy. 

They may be dislocated forwards or backwards. The forward lux- 
ation may be complete or incomplete ; with both sides equally advanced 
(" bilateral" of Malgaigne), or one of the articulating apophyses may be 
dislocated forwards, leaving the opposite apophysis in its place (" uni- 
lateral" of Malgaigne). 

Schranth 2 has collected twenty-four examples of luxation of the 
cervical vertebrae, of which four are recorded as dislocations forwards, 
two back, and six to the one side or the other. Three of this number 
were dislocations of the atlas, two were dislocations of the second 
vertebra, five of the fourth, two of the fifth, two of the sixth, and 
one of the seventh. In the other cases the seat was not stated. 

Malgaigne has brought together forty-five examples; of which 
twenty-one were complete forward luxations, .nine incomplete forward 
luxations, nine unilateral and forwards, and four were backward 
luxations. Three were dislocations of the second vertebra upon the 
third, four were dislocations of the third vertebra, ten of the fourth, 
eleven of the fifth, fifteen of the sixth, and two of the seventh. 

The bilateral forward luxations are generally caused by a fall upon 
the top and back of the head, or upon the top of the head while the 
neck is very much flexed forwards. The unilateral is caused gene- 
rally by a direct blow upon the back of the neck, the blow being 
probably directed somewhat to one side or the other. The number of 
backward luxations which have been reported are too few to enable 
us to indicate very accurately the general causes, but it seems proba- 
ble that they are most often occasioned by a fall upon the fore and top 
part of the head, received while the neck is bent forcibly back. 

1 Charles Bell, on Injuries of the Spine. 1824. 

2 Schranth, Anier. Journ. Med. Sci., May, 1848, from Arcliiv fur Phys. Heilkunde 



518 DISLOCATIONS OF THE SPINE. 

In dislocations of the cervical vertebrae forwards the head is usually 
depressed toward the sternum, in dislocations backwards the head is 
thrown back, and in unilateral dislocations the head is turned over 
one of the shoulders. Xeither of these malpositions of the head is 
uniformly present in these several dislocations, and indeed not un- 
frequently, especially in case the system is greatly shocked by the 
accident, the head and neck assume a preternatural mobility, and may 
be turned easily in any direction. 

The spinous process, unless the patient is very fleshy or consider- 
able swelling has supervened, can easily be felt, and its deviations to 
the right or to the left, forwards or backwards, furnish us with the 
most valuable and important sign of the dislocation. Even the trans- 
verse processes may be felt sometimes, especially in the upper part of 
the neck, with sufficient distinctness to render them useful in the 
diagnosis. 

To these circumstances we may add paralysis of the body below the 
seat of injury, with pain and swelling at the point of dislocation. In 
some cases also the patient has himself distinctly felt a cracking or 
sudden giving way in the neck at the moment of the accident. 

Prognosis. — The complete bilateral luxations, whether backwards or 
forwards, have in most cases terminated fatally within a short time, 
generally within forty-eight hours. Unilateral luxations are less 
speedy in their results, but when the dislocation remains unreduced, 
death generally takes place in a month or two. Lente relates a case 
of incomplete dislocation of the fifth cervical vertebra backwards, 
unaccompanied with fracture, which accident the patient survived 
five days. 1 A patient of Roux's lived eight days; but in the case 
of a second patient mentioned by Lente. with a complete luxation, 
without fracture, of the fifth vertebra, the patient survived the injury 
only two hours. 2 

On the other hand, occasional examples are presented of partial or 
complete recovery with the luxation unreduced. 

Horner, of Philadelphia, presented to the class of medical students 
of the University of Pennsylvania, in 1812, a lad aet. 10, who had fallen 
a distance of twenty feet, alighting upon his head. He was found 
senseless and motionless, with his head bent under his body. He 
gradually recovered from the shock, but his neck was stiflj distorted, 
and motionless, his face being inclined downwards to the right side. 
Two days after, his ''common and accurate perceptions returned, but 
he was affected for some time with tingling and numbness in his left 
arm.'" When presented to the class the transverse processes, from the 
fifth upwards, were about half an inch in front of those below, showing 
that the left oblique process of the fourth was dislocated forwards 
upon the fifth. The rotary motions of the neck could now be exe- 
cuted to some extent, but much more freely to the right than to the 
left. Professor Horner refused to make any attempt to reduce the 
dislocation. 3 

1 Lente, New York Journ. Med.. May. 1850. p. 2=4. 2 Lente, ibid., p. 397. 

3 Horner, Amer. Journ. Med. Sci., April, 1843, from Med. Exam. 



DISLOCATIONS OF SIX LOWER CERVICAL VERTEBRAE 519 

Dr. Purple, of Few York, lias reported a case of what was called a 
dislocation of the fifth and sixth cervical vertebrae, producing complete 
paralysis of the lower part of the body, in which the patient survived 
the accident many years ; but his lower extremities were so useless 
and cumbersome as to induce him, in the year 1851, six years after 
the injury had been received, to submit to the amputation of both at 
the hip-joint. In 1852, having become very intemperate, he died, but 
no autopsy was obtained, so that the exact character of the injury was 
never ascertained. 1 Sanson, of Paris, has reported also a case which 
came under his observation at Hotel Dieu, of dislocation of the "third 
cervical vertebra backwards," from which, although unreduced, the 
patient partially recovered. The character of this accident was not 
much better determined ; for, although he felt a severe and sharp pain 
at the moment of the injury, which was greatly aggravated by 
motion, and his head was bent forwards and to the left, "the chin 
being fixed on the upper part of the sternum," there was no paralysis 
of either the motor or sentient nerves. After the lapse of about four 
months he left the hospital, still unable to lift his chin more than four 
inches from the sternum ; after which he resumed his usual occupa- 
tions, suffering no further inconvenience than what was occasioned 
by the unnatural position of his head. 2 Notwithstanding the authori- 
tative testimony of Sanson that this was a dislocation backwards, one 
cannot avoid the conclusion that it was either a unilateral subluxa- 
tion, or perhaps a mere diastasis of the articulation, or else that it was 
an example of sprain of the muscles, and consequent contraction of one 
set, or paralysis of the opposing set of muscles. It is certain that it 
was not a complete luxation ; nor, since there was no paralysis of the 
body below the point of injury, can it be properly made use of as an 
argument for non-interference where such paralysis does actually exist. 

Let us see now what encouragement an attempt at reduction may 
offer, in a case which presents so little ground of hope where the 
reduction is not accomplished. 

Dr. Spencer, of Ticonderoga, 1ST. Y., relates that a man, set. 50, fell 
backwards from a board fence, striking upon the superior and anterior 
portion of his head, dislocating the second from the third vertebra of 
the neck. His head was thrown back so far as to prevent his seeing 
his own body, and all below the injury was completely paralyzed. 
Eepeated attempts were made to reduce the dislocation, "but the trans- 
verse processes had become so interlocked that every effort proved 
abortive," and he died forty- eight hours after the injury was received. 3 
Gaitskill also attempted reduction in a case of dislocation of the seventh 
cervical vertebra, but failed. 4 Boyer failed in two cases. It is related 
by Petit Eadel, that a young patient at La Charite expired in the 
hands of the surgeons, upon such an attempt being made a few days 
after the accident ; 5 and Dupuytren says "the reduction of these dislo- 

1 Purple, New York Journ. Med., May 1853, p. 319. 

2 Sanson, Amer. Journ. Med. Sci., Feb. 1836, p. 514 ; from Gaz. des Hopitaux. 

3 Spencer, Boston Med. and Surg. Journ., vol. x. No. 11. 
* Graitskill, London Repository, vol. xv. p. 282. 

5 Petit Radel, Note to Boyer, Malad. Chir., vol. v. p. US. 



520 DISLOCATIONS OF THE SPINE. 

cations is very dangerous, and we have often known an individual 
perish from the compression or elongation of the spinal marrow which 
always attends these attempts." 

Dr. Shuck, of Vienna, relates that a man, set. 24, while engaged at 
his work on the 5th of Dec. 1838, twisted his head suddenly round, 
in consequence of one of his companions roaring into his ear, when he 
instantly felt something give way in his neck, and found it impossible 
to move his head. Next morning his head was turned to the right 
and bent down toward the shoulder. Every attempt to move his head 
caused great pain. He complained of weakness in his right arm, but 
all the other functions of his body were perfect. An attempt was 
immediately made to reduce the dislocation by lifting him by the head, 
but without success. On the 7th of Dec, the weakness and numbness 
of the right arm had increased, and the attempt to reduce the bones 
was renewed. The patient was laid horizontally upon a bed, and ex- 
tension made from the chin and occiput while counter-extension was 
made from the shoulders. The force thus employed w T as gradually 
increased until the patient and assistant felt a snap as of two bones 
meeting, when it was found that the head was restored to its natural 
position, and the power of moving it had returned. The next day his 
arm was more powerless than before, and on the following day he had 
vertigo, but these symptoms soon yielded to copious bleedings, and he 
left the hospital cured on the 13th. 1 

Dr. Hickerman, of Ohio, has reported also, in the Ohio Medical 
Journal, a case of dislocation of one of the cervical vertebra?, the 
original account of which I have not seen, but only an abridged state- 
ment published in the Buffalo Medical Journal. By exploring the 
pharynx a prominence was felt opposite the junction of the fourth 
and fifth cervical vertebras ; and the action of the heart was barely per- 
ceptible. Seizing the patient's head under his left arm, Dr. Hickerman 
in this manner made traction, while, with the index finger of the right 
hand in the patient's throat, he made firm pressure obliquely upwards, 
backwards, and to the left; after continuing the pressure for about 
forty or fifty seconds, the part against which the finger was placed 
gradually, yet quickly, receded in the direction in which the pressure 
was made, and instantly, as quickly indeed as the act could be possibly 
executed, the patient opened her eyes, and natural respiration was es- 
tablished. She then also immediately became conscious of what was 
transpiring about her, and signified by signs, for she was yet unable 
to speak, that she had suffered pain in the epigastrium. Complete 
recovery took place. 2 

Schranth received under his care a patient who had a luxation of 
the "right transverse apophysis" of the fourth cervical vertebra, 
without lesion of the spinal marrow, which he reduced on the seventh 
day. The first attempt was unsuccessful ; but the second, made with 
great caution, by the aid of four assistants, three of whom pulled the 
head upwards while the fourth pressed with his whole weight upon 

1 Shuck, Araer. Joum. Med. Sci., July, 1841, p. 207. 

2 Hickerman, But. Med. Journ., vol. x. p. 702, April, 1855. 



DISLOCATIONS OF SIX LOWER CERVICAL VERTEBRJE. 521 

the shoulders, was completely successful. During the time that the 
traction was being made, the head was occasionally rotated slightly 
and moved laterally, and at the same moment the surgeon pushed 
firmly against the displaced apophysis. The reduction was attended 
with "various distinct crackings in the neck," which were loud enough 
to be heard. After some days of repose he resumed his occupation, 
no stiffness remaining in the movements of the neck. 1 

Dr. Edward Maxson, of Geneva, N. Y., was called on the 28th of 
Oct. 1856, to see a child about nine years old, who had met with a 
similar accident about forty hours before, namely a dislocation of the 
right articulating apophysis of the fifth or sixth cervical vertebra, 
occasioned by suddenly turning her head around while at play. She 
at first complained only of pain and inability to straighten the neck ; 
but whenever moved she became faint and irritable. A short time 
before the surgeon was called the mother had, in attempting to move 
her in bed, turned the face a little more to the left, when a severe 
convulsion immediately ensued. On examining the neck, Dr. Maxson 
discovered the displacement of the transverse process. Having ad- 
vised the parents of the danger necessarily incident to an attempt at 
replacement, and of the probable consequences of its being permitted 
to remain as it was, they consented that the trial should be made. "I 
grasped the head," says Dr. M., " with both hands, and proceeded 
according to Desault's method, only I first carried or turned the face 
very gently a little further toward the left shoulder, to, if possible, 
disengage the process; then lifting or extending the head, I turned 
the face very gently toward the right shoulder, when the difficulty 
was at once overcome, and she exclaimed : ' I can move my eyes.' 
Her countenance soon acquired a more natural appearance ; the faint- 
ness passed off; she rested quietly through the night; had no return 
of the difficulty, and needed only an emollient anodyne to soothe the 
irritation and slight swelling which remained at the point of injury." 2 

Rust, 3 Wood, of this city/ and others, have seen and reported simi- 
lar cases attended with like success. 

So far the cases of successful reduction which we have described 
are examples of dislocation of only one of the articulating apophyses, 
and they are sufficiently numerous to establish the value of the prac- 
tice. We have now to relate a case in itself unique, namely, a suc- 
cessful reduction of a dislocation of the fifth cervical vertebra, in which 
both apophyses appear to have been thrown forwards. It occurred 
in the practice of Dr. Daniel Ayres, of Brooklyn, N. Y. ; and will be 
best understood by a reproduction of his own published account of 
the case. 

" B. K., the subject of this accident, was a laboring man, thirty 
years of age, tall and muscular, but not fat, with a neck longer than 
the average among men of equal height. On the evening of the 2d 
of October he became intoxicated ; was brought home insensible, and 

1 Schranth, Arner. Journ. Med. Sci., May, 1848. 

2 Maxson, Buffalo Med. Journ., Jan. 1857, p. 479. 

3 Rust, Chelius, note by Smith. 

4 Wood, New York Journ. Med., Jan. 1857, p. 13. 
U 



522 DISLOCATIONS OF THE SPINE. 

did not recover from the combined effects of the shock and his liba- 
tions until the following morning, when he was supposed by his wife 
to be laboring under cold and a stiff neck. She made some domestic 
applications to the affected part, and administered a dose of cathartic 
medicine. When it was thought sufficient time had elapsed without 
obtaining relief, he was seen by Dr. Potter, of this city, and afterwards 
by Dr. Cullen, both of whom recognized a condition which was not 
only very unusual, but one which they had never before observed. I 
was then requested to examine the case, which I did on the ninth day 
after the accident. With some assistance and great personal effort, 
he was able to get out of bed, moving very slowly and cautiously. 
Desiring to expectorate, he was obliged to get down on his hands and 
knees, which he accomplished with the same deliberation. When 
seated in a chair, the head was thrown back and permanently fixed ; 
the face turned upward with an anxious expression. The anterior 
portion of the neck, bulging forwards, was strongly convex, rendering 
the larynx very prominent. The integuments of this region were 
exceedingly tense and intolerant of pressure. The posterior portion 
of the neck exhibited a sharp, sudden angle at the junction of the 
fifth and sixth cervical vertebras, around which the integuments lay 
in folds. It was difficult to reach the bottom of this angle even with 
strong pressure of the fingers, and of course the regular line formed 
by the projecting spinous processes was abruptly lost. He complained 
of intense and constant pain at this point, which was neither relieved 
nor aggravated by pressure. With difficulty he swallowed small 
quantities of liquid, pausing after each effort, and could not be induced 
to take solid food, since the first attempt to do so after the accident 
was followed by violent paroxysms of coughing and choking. His 
breathing was obstructed and somewhat labored, being unable fully 
to clear the bronchia of their secretion. This, however, seemed rather 
an effect of the tense condition of the soft parts of the neck, than the 
result of pressure upon the spinal cord, since he presented no evidence 
of paralysis, either of motion or sensation, in parts below the neck. 
The sterno-cleido-mastoid muscles of both sides were felt quite soft 
and relaxed. 

"But one conclusion could be formed upon this state of facts, to 
wit : that the oblique processes of both sides were completely dislo- 
cated. The marked rigidity of the head seemed to preclude the pro- 
bability of fracture through the vertebral bodies, and although the 
cartilage might be separated anteriorly, yet the body not pressing 
backwards sufficiently to produce paralysis of the cord, it was hoped 
that the posterior vertebral ligament remained uninjured ; it was, 
therefore, determined to make an effort at reduction on the following 
day. In addition to those originally connected with the case, I am 
under obligations to Drs. Ingraham, Turner, Palmedo, Gr. D. Ayres, 
and a number of other medical gentlemen, who were present by invi- 
tation, all of whom confirmed the diagnosis, and rendered efficient 
services. 

" The patient was placed upon a strong table in a recumbent posi- 
tion, with a pillow resting under the shoulders, the head being sup- 



DISLOCATIONS OF SIX LOWER CERVICAL VERTEBRA. 523 



Fig. 218. 



ported by the hand during the administration of chloroform, of which 
an ounce was given before anaesthesia ensued. Counter-extension 
being made by two folded sheets placed obliquely across the shoulders 
and properly held, the head was grasped by one hand placed under 
the chin, the other over the occiput, and by steadily and firmly draw- 
ing the head directly backwards, and then upwards, an attempt was 
made at reduction, but failed for want of sufficient power. Dr. Ingra- 
ham was then requested to place his hands immediately over my own 
in the same position as before, and 
steady traction was again made in the 
same direction. Our united strength 
was required in drawing the head 
backwards and upwards to dislodge 
the superior oblique processes from 
their abnormal position. When this 
was felt to be yielding by Dr. Cullen 
(who kept one hand constantly at the 
seat of dislocation), Dr. Potter was di- 
rected to place his hands under our 
own, still in position, and assist in 
bringing the head forwards; at the 
same time the chest was depressed 
toward the table. The bones were 
distinctly felt to slip into their places ; 
the line of the spine was instantly re- 
stored, the head and neck assuming 
their natural position and aspect. As 
soon as the patient became conscious, 
he expressed himself ignorant of what 
had taken place, but free from pain, 
and, in his own language, 'all right.' 
A bandage was arranged to support 
the head and keep it bent forwards. 
He had an anodyne for two nights fol- 
lowing, after which no further treatment was necessary, and at the 
end of one week he had complete control over the movements of the 
head and neck. Beyond the debility and emaciation immediately 
dependent upon protracted fasting and loss of rest, he has experienced 
no uneasiness since the operation. His appetite is now good, and all 
the functions perform their duty normally. In a subsequent inquiry, 
to determine, if possible, the cause of the accident, he states that he 
distinctly recollects going into a store in Atlantic Street, near the 
ferry, and there having angry words with an acquaintance ; that he 
left the store, and was proceeding up the street (which is here a rather 
steep ascent), when he was violently struck from behind, over the 
lower portion of the neck. He likewise remembers falling forwards, 
and striking against some object, but does not know what it was, nor 
what took place until the following morning." 1 




Ayres' case of bilateral dislocation of the 
fifth cervical vertebra. 



Ayres, New York Journ. Med., Jan. 1857, p. 9. 



524 DISLOCATIONS OF THE SPINE. 

§ 4. Dislocations of the Atlas. 

Surgeons have met -with several forms of displacement between the 
atlas and axis. First, a forced inclination forwards of the atlas upon 
the axis ; in consequence of which the body or anterior arch of the 
atlas is made to recede from the odontoid process, and the transverse 
ligament glides upwards without breaking, so that the extremity of 
the odontoid process comes to occupy a position underneath or behind 
the ligament, and thus presses upon the cord. It is apparent also that 
this form of displacement cannot occur without a rupture of the ver- 
tical ligament which binds the transverse ligament to the axis, nor 
without a separation of the atlas from the axis posteriorly and a rup- 
ture of the posterior atlo-axoidean ligament. Second, a similar incli- 
nation of the atlas, accompanied with a rupture of the transverse and 
superior vertical ligaments, in consequence of which also the odontoid 
process is allowed to fall upon the cord. Third, the atlas in the same 
position, with the odontoid process broken at its base. Fourth, the 
atlas displaced directly forwards or backwards ; and fifth, a displace- 
ment of only one articular process in a direction forwards. 

We have already, when speaking of fractures of the atlas, or of the 
atlas and axis together, called attention to several examples of that 
form of the dislocation which is accompanied with a fracture of the 
odontoid process. The other forms of dislocation are characterized 
by so few symptoms peculiar to themselves, or which can be regarded 
as diagnostic and not already sufficiently studied in connection with 
other dislocations of the neck, that we shall not deem it necessary to 
do more than remind our readers that if permitted to remain unre- 
duced a speedy and fatal issue is inevitable, and to point them to a 
couple of examples of recovery, after reduction has been fortunately 
accomplished ; for both of which I am indebted to Malgaigne. These 
may alone suffice to show that Dupuytren was in error when he 
declared that such accidents were wholly beyond the resources of 
our art. 

An old man received upon his head a bundle of hay cast from the 
top of a wagon. He fell with his head bent forwards so that his chin 
touched the top of the sternum, and in this position it remained 
immovably fixed ; all the other portions of his body preserved their 
natural functions. A surgeon, who was indeed the father of Mal- 
gaigne, being called, assured the patient that unless he could give him 
relief he certainly would die; but that inasmuch as the attempt might 
itself prove fatal, he ought at once to put in order his affairs. Accord- 
ingly the man- partook of the sacrament ; then the surgeon seated him 
upon the ground, and placing himself at his back with his knees 
resting upon his shoulders for the purpose of making counter-exten- 
sion, and with a towel brought over his own shoulders and under the 
chin of the patient for extension, he proceeded to act upon the neck in 
the direction of the axis of the spine. The efforts were long and pain- 
ful, but at last, while the head was lifted as far as possible, it was sud- 
denly drawn backwards, and immediately it resumed its natural 



DISLOCATIONS OF THE HEAD UPON THE ATLAS. 525 

direction. Absolute quietude was enjoined, and the patient recovered 
in a short time and without any accident. 

This patient was seen two years after by the younger Malgaigne, at 
which time no trace of the accident remained, except an impossibility 
of turning the head to the right or to the left. 

The other example is related by Ehrlich,.but in this case the dislo- 
cation was backwards. A young man ; set. 16, while carrying a sack 
of flour up a ladder, fell backwards, and the sack falling over upon his 
face and head came to the ground before him. He was found lying 
with his head thrown back and to the right, the head resting upon the 
scapula of this side, but having so completely lost its " solidity" that 
by its own weight it would fall from one side to the other. On the 
front and left side of the neck there existed a prominence supposed 
to be formed by the atlas ; the patient was unconscious ; the pulse was 
scarcely perceptible, and the whole body was suffering under paralysis. 
Ehrlich directed the shoulders to be held by one assistant, and the 
head to be drawn upon by another, while he pressed with his own 
hands forcibly upon the displaced atlas from behind. After several 
fruitless attempts, the reduction took place, accompanied with a sound 
distinctly audible to all of the assistants ; the head resumed its posi- 
tion firmly, and the arms began to move. The head was afterwards 
maintained in place by a bandage. The cure proceeded rapidly, and 
after a time no trace of the injury remained but a disagreeable tension 
in the nape of the neck whenever he moved his head briskly to the 
one side or the other. 1 



§ 5. Dislocations of the Head upon the Atlas, or Occipito-Atloidean 

Dislocations. 

Lassus, Palletta, and Bouisson 2 have each reported one example of 
this dislocation. In neither case was the dislocation complete, but 
death occurred speedily in every instance. Dariste exhibited to the 
Anatomical Society of Paris, in 1838, a specimen of incomplete luxa- 
tion of the occipito-atloidean articulation, with stretching of the 
transverse ligament. The patient from whom the specimen was taken 
having lived more than a year after the accident, when he died from a 
tubercle in the brain. 3 

1 Malgaigne, Ehrlich, Malgaigne, op. cit., torn. ii. p. 334. 

2 Lassus, Palletta, Bouisson, Malgaigne, op. cit., p. 320. 

3 Dariste, Amer. Journ. Med. Sci., Nov. 1838, p. 237, from Archives Grea., May, 
1838. 



526 DISLOCATIONS OF THE BIBS. 



CHAPTER IT. 

DISLOCATIONS OF THE RIBS. 

The ribs may be separated from the bodies of the vertebrae, from 
the cartilages of the ribs, and from each other. The cartilages of the 
ribs may also be separated from the sternum. 

§ 1. Dislocations of the Ribs prom the Vertebrae. 

The heads of the ribs are joined to the bodies of the vertebrae by 
strong ligaments. The articulations are ginglymoid ; admitting of 
motion chiefly in the direction of the axis of the spine. The mobility 
gradually increases as we proceed from the first rib downward to the 
last. Each joint is furnished with a capsule. 

The necks and tubercles are also united to the transverse processes 
by ligaments, and the articulations are furnished with synovial cap- 
sules. 

I am not aware that any examples have ever been reported of dis- 
locations of the ribs from the transverse processes. 

Examples of dislocation of the heads of the ribs have been mentioned 
by Ambrose Pare, Bransby Cooper, Alcock, Donne, Henkel, Kennedy, 
Buttet, and some others; but most of these reputed cases have not 
borne the test of a critical analysis, and while Tidal (de Cassis) is in 
doubt whether the claims of even one have been fully established, 
Boyer denies absolutely its possibility. "VTe see no reason, however, 
to question the authenticity of several of these examples. 

The case mentioned by Bransby Cooper, although very briefly 
narrated, leaves no room for doubt as to its real character. u Mr. 
"Webster, surgeon at St. Albans, when examining the body of a 
patient who had died of fever, found the head of the seventh rib 
thrown upon the front of the corresponding vertebra, and there 
anchylosed. Upon inquiry, Mr. Webster learned that this gentle- 
man, several years before, had been thrown from his horse across a 
gate, for which accident he had been subjected to the treatment usually 
followed in fractures of the ribs, and there is every reason to believe 
that it was at this time that the dislocation occurred." 1 

These accidents seem to have been generally occasioned by a fall 
or a blow upon the back, and the dislocation has been accompanied, 
usually, with a fracture of some other rib, or of the transverse or 
spinous processes of the corresponding vertebras. The head of the 

1 Webster, B. Cooper's ed. of Sir Astlev Cooper, Ainer. ed., p. 450. 



DISLOCATIONS OF THE KIBS FROM THEIR CARTILAGES. 527 

rib has always been found to be displaced inwards. The lower ribs, 
including the false and floating, are those which have been most fre- 
quently displaced. 

It would be difficult, if not impossible, during the life of the patient, 
to make a positive diagnosis, since the symptoms resemble so closely 
those which accompany a fracture of the rib near its posterior ex- 
tremity. The nature of the accident producing the dislocation, the 
depression, mobility, and pain, are equally indicative of a fracture ; 
while the failure to detect crepitus might easily be explained by the 
thickness of the muscular walls at this point, or by the riding, or by 
other displacements of the broken fragments. 

Chelius speaks of a peculiar "rustling," perceived when the body and 
ribs are moved by the surgeon or by the patient himself, and which 
is different from the sensation produced by emphysema or fracture. 

The treatment ought to be the same which would be adopted in 
case the rib was broken. Replacement of the dislocated bone must be 
regarded as impossible ; and it only remains that we insure quiet as 
far as possible in this portion of the chest, and combat the pain and 
inflammation by suitable remedies. The circular bandage, however, 
recommended in these cases by Sir Astley Cooper, could only be 
serviceable in dislocations of those ribs which have an attachment to 
the sternum; the floating ribs, which have been found dislocated quite 
as often as either of the others, could derive no support from circular 
pressure, or from any other mechanical contrivance. 



§ 2. Dislocations of the "Ribs from their Cartilages, and of the Car- 
tilages from the Sternum. 

The cartilage of the first rib has no proper articulation at either 
extremity, but the remaining six upper ribs, where they join the 
sternum, are furnished with synovial capsules. In old age these 
articulations generally disappear, yet not always. 

Charles Bell observes: "A young man playing the dumb-bells and 
throwing his arms behind him, feels something give way on the chest; 
and one of the cartilages of the ribs has started and stands prominent. 
To reduce it, we make the patient draw a full inspiration, and with 
the fingers knead the projecting cartilage into its place. We apply a 
compress and bandage, but the luxation is with difficulty retained." 

Ravaton, Manzotti, and Monteggia, have each, according to Mal- 
gaigne, reported one example of traumatic dislocation ; in all of which 
the cartilages were thrown forwards in advance of the sternum. 

When treating of fracture of the sternum I have related one case 
which has come under my own observation of dislocation of three or 
four cartilages at the same time. 

By pressure alone they have generally been replaced, the cartilage 
resuming its position suddenly and with a sound. The reduction 
may, nevertheless, be facilitated by bending the trunk backwards or 
by directing the patient to make a full inspiration. 

To maintain the reduction has been found more difficult, and Sir 



£9< 



DISLOCATIONS OF THE BIBS. 



Astley directs that "a long piece of wetted pasteboard should be 
placed in the course of three of the ribs and their cartilages, the 
injured rib being in the centre; this dries upon the chest, takes the 
exact form of the parts, prevents motion, and affords the same support 
as a splint upon a fractured limb. A flannel roller is to be applied 
over this splint, and a system of depletion pursued, to prevent inflam- 
mation of the thoracic viscera." Instead of the pasteboard, we might 
use either felt or gutta perch a. 

The patients spoken of by Ravaton and Manzotti were both cured 
in about one month. 

Mr. Bransby Cooper says that a baker's boy applied for relief at 
Guy's Hospital, who was the subject of displacement of the cartilages 
of the fifth and sixth ribs from their junction with the sternum, pro- 
duced partly by the constant action of the pectoral muscles in kneading 
bread, but principally by his defective constitution. Mr. Cooper stated 
to the boy the necessity of changing his occupation, and advised him 
to go into the country, but as he was unable to do so little hope was 
entertained of his recovery. 1 



§ 3. Dislocation of one Cartilage upon Another. 

The cartilages of the sixth, seventh, and eighth ribs are furnished 
at their lower borders with a true arthrodial joint, by which they 
articulate with the corresponding cartilages. This arrangement some- 
times extends to the fifth and sixth ribs. 

A displacement of these articulations may take place when one 
falls upon his back, striking upon some projecting body, so that the 
chest is suddenly thrown forwards; in consequence of which the 
upper margin of the lower cartilage is depressed and entangled be- 
hind the lower margin of the upper. The inferior cartilage is, there- 
fore, the one which is displaced rather than the superior, although 
this latter being made prominent by the pressure of the other from 
behind, seems alone to be displaced. Boyer, Martin, and Maigaigne 
have each reported one example. 

It is probable that the contraction of the pectoral and abdominal 
muscles has a chief agency in the production of these dislocations, and 
that they are not solely or directly due to the shock of the accident. 

The treatment consists in pressing firmly upwards and backwards 
against the inferior margin of the upper, or overlapping rib, so as to 
disengage it from the lower, when by its own elasticity it will resume 
its natural position. The reduction might also be aided by a full in- 
spiration. 

1 B. Cooper's ed. of Sir Astley Cooper, &c, op. cit., p. 447. 



DISLOCATION FORWARDS AT THE STERNAL END. 529 



CHAPTER Y. 

DISLOCATIONS OF THE CLAVICLE. 

Of 30 dislocations of the clavicle observed by me, 6 belonged to the 
sternal end and 24 to the acromial. Of those belonging to the sternal 
end, 4 were dislocations forwards, 1 was a dislocation upwards, and 1 
a dislocation forwards and upwards. I have never met with a dislo- 
cation backwards. Of the acromial dislocations, the whole number 
were dislocations upwards, or upwards and outwards. 

§ 1. Dislocation Forwards at the Sternal End. 

Causes. — This accident is generally caused by a fall upon the point 
of the shoulder, in consequence of which the sternal end of the cla- 
vicle is driven forcibly inwards and forwards. It is probable, also, 
that the blow which produces the dislocation is received rather upon, 
the anterior and outer face than exactly upon the extremity of the 
shoulder. A sudden effort of the muscles, as in the attempt to 
balance a weight upon the head, or to throw the shoulders backwards 
when under drill, has been known also to produce this dislocation. 
In one example it was occasioned by placing the knee against the 
spine and drawing the shoulders forcibly back. "Various other acci- 
dents, the philosophy of whose agency is not so easily explained, are 
said to have produced the same result ; but it is not improbable that 
in many of these cases the precise manner in which the injury was 
received has not been correctly understood or reported. 

Mr. Fergusson has once seen this displacement in a newly-born in- 
fant, which had, happened during birth. It could be replaced with 
ease, but immediately slipped out again when left to itself. "Nothing 
was done; a new joint formed, and the child afterwards possessed as 
much power in the one arm as in the other." 1 

Symptoms. — The head of the bone, unless the person is exceedingly 
fat, or great swelling has supervened, can be distinctly felt and seen 
in front of the sternum; the corresponding shoulder falls a little back ; 
the head inclining also sometimes to the same side ; the movements of 
the arm are embarrassed, and accompanied almost always with an acute 
pain at the point of dislocation. The clavicular portion of the sterno- 
cleido-mastoid muscle presents an unusually sharp and projecting out- 
line, and a careful measurement indicates, if the dislocation is com- 
plete, a sensible approach to the acromion process toward the centre 



1 Fergusson, System of Practical Surgery, Amer. ed., 1853, 



p. 203. 




530 DISLOCATIONS OF THE CLAVICLE. 

of the sternum. If now the surgeon places his knee against the spine, 
and draws the shoulders back, the projection of the clavicle in front 
diminishes or disappears ; if he carries the shoulder up, it descends ; 

and if he depresses the shoulder, it 
Fig. 219. ascends. 

The simplicity and uniformity of 
the symptoms which usually charac- 
terize this accident will generally pre- 
vent the possibility of a mistake ; but 
Pinel mentions the case of a man who 
having presented himself at one of the 
hospitals of Paris, suffering under this 
dislocation, the surgeon in chief 
thought it a tumor of the bone, and 
advised the application of a plaster; 
and, on the other hand, a patient pre- 
sented himself to Velpeau, who had 
been treated for a dislocation, when 
Dislocation of the stemai end forwards. the bone was only expanded by dis- 
ease. 
I have myself also seen a fracture so near the sternal end of the 
bone as not to be easily distinguished from a dislocation. 

Pathology. — In complete anterior luxation of the clavicle, the cap- 
sular ligament suffers a complete disruption, and also the anterior 
with the posterior sterno-clavicular ligaments. The rhomboid and 
interarticular ligaments suffer more or less according to the extent of 
the displacement. The interarticular cartilage may retain its attach- 
ment to the sternum, or it may be carried forwards with the clavicle. 
The head of the bone lies immediately underneath the skin and in 
front of the sternum ; and generally it is found to have descended a 
little upon its anterior surface. Eicherand saw a case in which the 
sternal extremity of the bone was placed three inches below the top 
of the sternum. 

Wherever the bone lies it carries with it the clavicular fasciculus 
of the sternocleidomastoid muscle. 

Treatment. — Not one of the six forward dislocations of the clavicle 
seen by me has been completely reduced, or if reduced they have not 
been retained in place. In the following example the reduction, al- 
though faithfully attempted, was never accomplished. 

Mr. H., of Buffalo, set. 45, was thrown by a horse, suffering at the 
same moment a fracture of the leg and a forward dislocation of the 
left clavicle at its sternal end. 

Prof. James P. White, with whom I was in consultation, made 
several attempts to reduce the dislocation by placing the knee against 
the spine and pulling the shoulders forcibly back, and the same efforts 
were repeated by myself, but without accomplishing the reduction. 
We also endeavored to reduce it hy pressing directly upon the pro- 
jecting bone and by placing a pad in the axilla, using the arm as a 
lever as recommended by Desault, and with no better result. 

This patient was tolerably muscular, but while we were manipu- 
lating he was very much enfeebled by the shock of the accident. 



DISLOCATION FORWAEDS AT THE STERNAL END. 531 

Finding that it was impossible to reduce the dislocation by any 
moderate amount of force, and believing that if we were to succeed 
we could not retain the bone in place, and the more especially because 
his left side was so much bruised that he could not bear an axillary 
pad or bandages of any kind, we desisted from any further attempts. 

Two years later I examined the shoulder and found the clavicle 
still unreduced, and its position unchanged. When he carries the 
shoulder forwards or backwards, there is a corresponding motion at 
the sternal end of the clavicle. The arm is not quite as strong as the 
other, and its freedom of motion is slightly impaired. 

I have also in my museum the cast of a case of complete forward 
dislocation at this point ; which accident occurred in a lad twelve 
years old, who had fallen into a cellar on the 20th of Aug. 1856. The 
late Dr. Lewis and Dr. Dayton, both excellent surgeons, had examined 
the arm, and dressings had been applied with a view to maintain the 
reduction ; but on the fifth day after the accident I found the bone 
displaced ; nor do I think reduction was ever afterwards maintained. 

A lad was brought into the Buffalo Hospital of the Sisters of 
Charity, with a dislocation of the same character, on the 25th of Sept., 
1858, who had been run over by a wagon on the same day. Dr. E. 
P. Smith, one of the surgeons of the hospital, attempted faithfully to 
reduce it, but was unable to do so. Five days after, I found the bone 
out and quite movable. All apparatus having been removed, we laid 
him upon his back in bed, and kept him in this position three weeks. 
He was then dismissed with no change in the appearance of the bone, 
but he could move the arm as well as before the accident. 

Other surgeons have not met with, or at least they have not men- 
tioned any cases in which the reduction of this dislocation was attended 
with difficulty, nor am I prepared to explain the difficulty which was 
experienced in my own (Mr. H.), and in Dr. E. P. Smith's case. Pro- 
bably they ought to be regarded as exceptions to the general rule. 
But most surgeons have testified to the difficulty of retaining it in 
place when reduction has been fairly accomplished. Chelius says 
"there commonly remains more or less deformity," and Malgaigne 
says that " it is difficult and rare to cure it without deformity." 

Nevertheless, Desault (or, rather, his pupil Bichat, who has published 
his lectures), who always speaks very confidently of his ability to retain 
either broken or dislocated bones in their places, says that he " almost 
always obtained complete success" with his apparatus. It is remark- 
able, however, that of the three examples furnished by Bichat to con- 
firm this statement, all of which were treated by Desault himself, one 
recovered after a long time with a " very perceptible protuberance in 
front of the sternum," one with a " very slight protuberance," and in 
the other the " swelling was almost gone" on the twentieth day, and 
we are left in doubt as to whether the reduction was any more com- 
plete than in either of the other cases. 1 Eicherand and Guersant suc- 
ceeded no better with Desault's dressings. 2 



1 Desault on Fractures and Dislocations, by Xav. Bichat, Phils 

2 Malgaigne, op. cit., torn. ii. p. 417. 



lada. ed., 1805, p. 53. 



532 



DISLOCATIONS OF THE CLAVICLE. 



Other surgeons have made similar claims for their own forms of 
apparatus, but experience still continues to show that a complete re- 
tention of the dislocated bone is 
seldom to be expected. 

Sir Astley Cooper recom- 
mends an apparatus, the con- 
struction and application of 
which are illustrated by the ac- 
companying sketch, the object of 
which is to draw the shoulders 
back, and at the same time, by 
the aid of two pads or cushions 
in the axillae, to carry the 
shoulders outwards. The dress- 
ing is then completed by placing 
the arm in a sling. He advises, 
however, that in some way 
direct pressure should be made 
upon the projecting point of 
bone. 

Yelpeau objects to any plan 
which will draw the shoulders 
back ; but, on the contrary, he 
thinks that the shoulders should 
be kept slightly forwards so as 
to diminish the tendency of the 
sternal end of the clavicle to escape in this direction. 

Dr. Folts, of Boston, affirms that he has been able in one instance 
to maintain complete reduction with Bartlett's apparatus for broken 
clavicles. 1 

Until further observations have determined the relative value of 
these and of many other processes, it will be well to adopt no fixed 
rule of action ; but, having reduced the bone by either placing the 
knee upon the spine and drawing the shoulders back, or by making 
use of the humerus as a lever, we recommend that the surgeon shall 
seek to maintain it in place by such means as the experiment shall 
prove are most successful. Among these means, direct pressure upon 
the sternal end of the clavicle, the sling, and perfect quietude of the 
muscles of the arm through the aid of bandages, are no doubt of the 
greatest importance, and can seldom be omitted. If then we find that 
a position of the shoulders more or less forwards or backwards best 
maintains the apposition, this position, whatever it is, ought to be 
continued. 

In order to be successful, sufficient time must elapse for the torn 
ligaments to become firmly reunited, during which the reduction must 
be constant; since every time the bone escapes, the whole work of 
repair has to be recommenced as from the beginning. To this end at 
least four or six weeks are necessary, and sometimes the period must 




Sir Astley Coopers apparatus for dislocated clavicle. 



Folts, Boston Med. aril Surg. Jouru., vol. liii. p. 230. 



OF THE STERNAL END OF CLAVICLE UPWARDS. 533 

be lengthened far beyond these limits ; so that it may often become a 
grave point of inquiry whether the long confinement of the limb will 
not entail more serious consequences than have ever been known to 
arise from leaving the bone displaced, which in no case yet reported 
has more than slightly impaired the functions of the arm. 



§ 2. Dislocation of the Sternal End of the Clavicle Upwards. 

Malgaigne has collected four undoubted examples of this dislocation, 
and I have been unable to find a report of any other except the very 
extraordinary case described by Dr. Rochester, at the September 
meeting of the Buffalo Medical Association, and which case, through 
the courtesy of Dr. Rochester, I was permitted to see several times. 1 

Jerry McAulifte, set. 44, on the 28th of August, 1858, while seated 
upon a load of wood, was caught under the bar of a gateway and 
violently crushed, the right shoulder being forced downwards and a 
little backwards. Dr. Rochester saw him very soon after the accident. 
On examination, it was found that the sternal extremity of the right 
clavicle was thrown upwards so far as to rest upon the front of the 
thyroid cartilage, occasioning considerable pain, difficulty of respira- 
tion, and loss of speech. Reduction was easily effected, and a retentive 
apparatus was immediately applied, consisting of a gutta-percha splint, 
moulded to the clavicle and ribs, and retained in place with adhesive 
plaster. Suitable bandages, a sling, &c, were also employed to main- 
tain complete rest. 

Notwithstanding all the care employed, the bone again became 
displaced, and when, near four months after the accident, this man 
came before the class of medical students at the Hospital of the Sisters 
of Charity, we found the sternal end of the clavicle carried upwards 
half an inch, and across toward the opposite side also about half an 
inch, and projecting somewhat in front. It was fixed in this position 
by ligaments which allowed it to move much more freely than natural, 
but which would not permit any great displacement. The correspond- 
ing shoulder was slightly depressed. McAuliffe said that he felt no 
inconvenience or abatement of strength in the arm except when he 
attempted to lift weights above his head. 

The accident seems to have been produced in all the cases, so far 
as can be ascertained, by a force operating upon the end and top of 
the shoulder; in consequence of which the head of the clavicle is 
pushed and at the same time lifted, as it were, from its socket, tearing 
not only its capsule with the ligaments which immediately invest the 
capsule, but also in some instances the costoclavicular ligament with 
some fibres of the subclavian muscle. The sternal end of the clavicle 
is found riding upon the top of the sternum, its head being placed 
between the sternal fasciculus of the sterno-cleido-mastoid muscle 
on the one hand, and the sterno-hyoid muscle on the other. In 
one of the cases seen by Malgaigne the head had traversed in this 

1 Rochester, Buffalo Med. Journ., vol. xiv. p. 262. 



53i DISLOCATIONS OF THE CLAVICLE. 

direction completely the intra-clavicular space, and lay behind the 
sternal portion of the opposite sterno-cleido-mastoid muscle. 

The symptoms are. a depression of the shoulder, with an elevation 
of the sternal end of the clavicle so as to increase sensibly the space 
between it and the first rib. The clavicle also encroaches more or 
less upon the supra-sternal fossa, occasioning a correspondiDg dimi- 
nution of the space between the end of the shoulder and the centre of 
the sternum. The sternal portion of one or both of the sterno-cleido- 
mastoid muscles may also be seen raised and rendered tense by the 
pressure of the head of the bone from behind. 

Eeduction has been found easy, but Malgaigne thinks a perfect 
retention impossible, at least it does not seem to have been accom- 
plished in any of the cases reported, although in most or all of them 
the remaining deformity was only slight. In no case did this trifling 
displacement seriously impair the functions of the arm. 

The same apparatus to which we shall give the preference in cases 
of dislocation upwards of the acromial end of the clavicle, at least with 
only such slight modifications as the peculiarities of the case will 
naturally suggest, will be suitable for this accident. The shoulder 
must be lifted by a sling, while the sternal end of the clavicle is 
pressed downwards by a pad and bandages : and all the muscles of the 
arm and chest, so far as is consistent with respiration and comfort, 
must be maintained in a state of perfect rest until the ligaments have 
become reunited. 



§ 3. Dislocations or the Sternal End oe the Clavicle Backwards. 

The first case upon record of this kind of accident, caused by 
violence, was published by Pellieux in 1834, in the Revue Mi 
until which time its existence had been generally denied. In the 
London and Edinburgh Journal of Medical Science for October, 1541, 
several cases are mentioned. 

Two forms of the accident have been described, one in which the 
head of the clavicle is driven backwards and a little downwards; and 
another in which it is displaced directly backwards, or backwards and 
a little upwards. In both of these classes, the end of the bone falls 
inwards toward the opposite clavicle, and occupies a space in the 
cellular tissue back of the sterno-hyoid and sterno-thyroid muscles, 
and in front of the oesophagus : the trachea, if reached at all, being 
probably thrust to the opposite side. 

The examples in which it has been found below the top of the 
sternum are much the most numerous; indeed, it is probable that the 
other form is only a secondary displacement, occasioned by the action 
of the fibres of the sterno-cleido-mastoid muscle. 

Causes. — Of the eleven examples mentioned by Malgaigne, four 
were occasioned by direct blows, and most of the remainder by crush- 
ing accidents, as by powerful lateral compression of the shoulder-. 

One of the cases produced by a direct blow was accompanied with 
an external wound, and is the only instance of a compound dislocation 



OF THE STERNAL END OF CLAVICLE BACKWARDS. 535 

of this kind upon record. The man was admitted into St. Thomas's 
Hospital in Sept. 1835, and, according to his own account, the sharp 
end of a pickaxe had been driven through the flesh against the bone. 
The sternal end of the clavicle was found to be displaced backward, 
and with the finger thrust into the wound on the front of the chest, it 
could be distinctly felt resting upon the side and front of the trachea, 
where it interfered somewhat with respiration and deglutition. He 
had a great desire to cough, with a sensation of pressure on his wind- 
pipe, which was greatly increased when his head was thrown back. 
There was also a slight emphysema in the region below the collar-bone 
and over the top of the sternum. The shoulder having been brought 
back with straps attached to a back-board, the bone readily resumed 
its place. The elbow was then brought forwards and bound to the 
side, and the wound being closed with adhesive plaster, he was put to 
bed with the shoulders much raised. No unfavorable symptoms fol- 
lowed, and in three weeks he left his bed. Three weeks later he left 
the hospital with the sternal end of the bone still falling a little back- 
wards, and rather more movable than natural. 1 

The following example, related by Morel-Lavallee, will illustrate 
that class in which the dislocation results from an indirect blow, or 
from a crushing accident. 

Lemoine, seventeen years old, had his right shoulder violently 
pressed against a wall by a carriage. He experienced at the moment 
some pain at the bottom of his neck, and a great sensation of suffocation, 
which lasted for more than a quarter of an hour. The dyspnoea gradu- 
ally subsided, but the motion of the right arm not returning, he, on 
the eighth day after the accident, entered La Charite. On examination, 
the two shoulders were found to be on the same level, but the right 
one was nearer the median line. The internal extremity of the clavicle 
was half concealed behind the sternum. On depressing the shoulder, 
the inner end of the clavicle arose and disengaged itself from behind 
the sternum; but reduction was effected by elevating the shoulder, 
while at the same time it was carried outwards and backwards. De- 
sault's bandage was then applied, but as it became loosened, Velpeau's 
was substituted, which kept the bone completely in position until the 
eighteenth day, when the patient was lost sight of. 2 

Symptoms. — The most constant symptoms are, the absence of the 
head of the bone from its socket, and its complete or partial disap- 
pearance behind the sternum, an approach of the corresponding shoul- 
der to the median line, an inclination of the head to the opposite side, 
elevation of the shoulder, pain at the bottom of the neck, impairment 
of the motions of the arm, sometimes difficulty in respiration and in 
deglutition, partial arrest in the circulation of the arm from pressure 
upon the subclavian artery, and a slight projection of the acromial end 
of the clavicle, noticed twice by Morel-Lavallee. 

It has not generally been found difficult to reduce this dislocation, 
nor, when reduced, is it so liable to again become displaced as are the 

1 South, note to Chelius's Surgery, Amer. erh, vol. ii. p. 218. 



536 DISLOCATIONS OF THE CLAVICLE. 

dislocations forwards ; yet in only a few instances has the restoration 
been so complete as not to leave some deformity. 

In order to the reduction, the shoulder must be carried generally 
upwards, outwards, and backwards, and it may then be best main- 
tained in position by laying the patient on his back upon an elevated 
cushion, as practised by Tyrrell in the case related by South. To this 
may be added such other measures, differing but little from those em- 
ployed in other dislocations of the clavicle, as are necessary to insure 
complete rest to the muscles. Of course, no pads or bands across the 
clavicle can be of any service in this case. 

As in the other cases of dislocation at this point, the patients have 
generally recovered nearly the full use of their arms, even in one or 
two instances in which the reduction has never been accomplished. 



§ 4. Dislocation of the Acromial End of the Clavicle Upwards. 

Of all the dislocations of the clavicle, this form is most frequent. 
I have met with it either as a partial or complete luxation twenty-four 
times. The youngest subject was seven years of age, and the oldest 
sixty-three. All but one were males. 

Causes. — It is produced generally by a fall upon the extremity of 
the shoulder. Twice the blow has been received rather upon the 
back than upon the extremity, and once it was occasioned by the fall 
of a board directly upon the top of the shoulder, and once by a bolt 
thrust directly up from under the clavicle. 

Symptoms. — When the dislocation is complete, the clavicle not only 
is lifted from its articular facet to the extent of the breadth of the 
bone, but it is pushed more or less outwards over the top of the acro- 
mion process ; generally less than half an inch, but I have once seen it 
riding the process to the extent of three-quarters of an inch. In this 
last example, the case of James Moran, a strong, healthy laboring man, 
the clavicle was easily reduced, and it always went into place with a 
sensible click; but although every possible care was taken to retain 
it in place by bandages, compresses, an axillary pad, and a sling, yet 
it was not accomplished, and on the third day he removed all the 
dressings, and refused to have them reapplied. 

I have usually found the shoulder slightly depressed ; and in one 
instance where it is probable the deltoid muscle had suffered some in- 
jury, the elbow hung away from the body, and any attempts to lay it 
against the side produced an acute pain in the shoulder. 1 It has been 
noticed also, in most cases, that the clavicular portion of the trapezius 
muscle appeared lifted and tense, especially when the neck was 
straight. 

Inability to raise the arm to a right angle with the body is a general 
but not constant symptom. In two instances, where the displacement 
was only moderate, the patients were at first and for some time after- 

1 Report on Dislocations, by the author. Trausac. of New York State Med. Soc, 
1855, p. 19. 



OF THE ACROMIAL END OF CLAVICLE UPWARDS 



537 



Q 

have 




Dislocation of the acromial end of 
the clavicle, upwards and outwards. 



wards unable to lift the arm in any degree from the side. In one 
example, a lady sixty years of age had fallen upon her shoulder and 
produced a dislocation upwards, but she had not consulted a surgeon 
until she called upon me, five months after 
the accident. The clavicle was then raised Fig- 221. 

from its socket about half an inch, but it 
could be easily pressed back to its place, 
the reduction being attended with a grat- 
a circumstance which I 
not noticed in any other instance. 
She was not even then able to raise her 
arm to her head, nor had she been able to 
do so since the accident occurred. 

* In all the motions of the arm and shoul- 
der, the clavicle is seen to move more 
freely than natural immediately under the 
skin, and these motions are usually at- 
tended with some pain at the point of dis- 
location. 

This accident has been sometimes mis- 
taken for a dislocation of the humerus, 
but unless the shoulder is already greatly 
swollen, the error is not likely to happen. 
If the point of the acromion process can 
be made out, it will be easy to determine, by sliding the finger along 
its spine, whether the clavicle is displaced or not, and by these means 
to settle the question of its complicity in the accident. The question 
as to whether the shoulder is dislocated or not may be more difficult 
of solution, as we shall hereafter have occasion again to observe. 

Pathology. — Generally there exists simply a rupture of the liga- 
ments immediately investing the joint, so that the clavicle rises from 
its socket only about half an inch, more or less, according to its dia- 
meter, and is carried outwards just sufficiently far to allow it to rest 
upon the upper margin of the acromial articulation. In at least nine- 
teen of the cases seen by me this has been the position of the acro- 
mial end of the clavicle, and for its complete reduction nothing more 
has been required than to press with moderate force upon the upper 
and outer end of the bone. 

In three cases I have found the bone not only thus lifted in its 
socket, but also driven over upon the acromion process from half to 
three-quarters of an inch ; and in one instance, that of a gentleman, 
Mr. B., who was injured in a railroad accident, the acromial end of 
the clavicle was displaced outwards half an inch and backwards three- 
quarters of an inch, while the sternal end also was considerably lifted 
in its socket and slightly sent inwards. The shoulder fell forwards 
and the coracoid process was one inch nearer the sternum than the 
same process upon the opposite side. In such cases more or less of 
the fibres of the coraco-clavicular ligament must have suffered a dis- 
ruption ; indeed, without a rupture of its external fasciculus, which 
35 



538 DISLOCATIONS OF THE CLAVICLE. 

anatomists have called the trapezoid ligament, such a dislocation can- 
not take place. 

Prognosis. — It is impossible for me to say what has been the pre- 
cise result in all the cases which I have seen, but my notes furnish 
only one case of perfect retention after a complete dislocation at this 
point. David Thomas, aged about twenty-five years, fell sideways 
upon the ground, striking upon the extremity, and, as he thinks, a 
little upon the top of the shoulder. I found the clavicle dislocated 
upwards and outwards, so that it overlapped the acromion process 
half an inch. It was easily replaced, and having applied my own 
apparatus for broken collar-bones, with the addition of a band across 
the shoulder and under the elbow to keep the clavicle down, I found 
that I had succeeded in retaining the bone in place. This dressing 
was continued until the forty-second day, when, on being removed, 
the clavicle was seen to be closely confined upon its articulation ; and 
after a lapse of two years it still retains its position so completely that 
no difference can be detected between the opposite articulations. 

In the case of Moran, already mentioned, whose clavicle overlapped 
the acromion process three-quarters of an inch, and who threw off the 
dressings at the end of three days, the same degree of displacement 
existed at the end of two years; the scapular end of the clavicle 
moving freely in every direction under the skin according as the arm 
was moved. In lifting, he says, the strength of his arm is undimin- 
ished until he raises the weight nearly to a level with his shoulders, 
and from this point upwards he can lift but little. For a laboring 
man it amounts to a serious maiming. I have seen the same loss of 
power in the arm to raise bodies above the head in at least two or 
three of the examples of less complete luxation, continuing after the 
lapse of several years; but in the majority of cases, although the 
bone does not remain reduced, the patients have recovered eventually 
the complete use of the arm in whatever position it may be placed. 

The case to which I have already referred as having been caused by 
a bolt thrust upwards under the clavicle, will furnish the best illustra- 
tion of this general principle. James O'Brien, 1st U. S. Artillery, 
was injured in September, 1862, by being run over by a horse-car. 
A bolt, three-quarters of an inch in diameter, was driven through 
the skin on the anterior margin of the left axilla, breaking the first 
rib, severing the coraco-clavicular ligaments, and forcing the clavicle 
upwards from its socket. No attempt at reduction was ever made. 
When seen by me one year after the accident, the outer end of the 
clavicle was lifted directly up two inches from the acromion process, 
to which it was united only by a long and slender ligament. He was 
not conscious of any loss of power or limitation of motion in the 
injured arm. At my request, my son, then in the U. S. service, insti- 
tuted a series of experiments to test the relative strength of the two 
arms, and with the following result : First with the right arm, and 
then with the left, he lifted from the ground fifty-six pounds and three 
ounces, and sustained this weight above his head 30 seconds, with his 
arms fully extended. With his right arm extended at full length, at 



OF THE ACROMIAL END OF CLAVICLE UPWARDS. 539 

right angles with his body, he sustained twenty-five pounds for fifteen 
seconds. With the left arm he sustained the same weight, in the same 
position, seventeen seconds. 1 

Treatment. — When the bone simply rises upon its socket, the re- 
duction is always easily accomplished by pressing firmly upon its 
extremity with the fingers ; but if, at the same time, it has been car- 
ried outwards, or outwards and backwards, the reduction is only 
accomplished by pulling the shoulders backwards, or by placing a 
pad in the axilla, using the arm as a lever, or by lifting the arm by 
the elbow and at the same time pressing the clavicle down ; and it 
will sometimes require the application of all or several of these pro- 
cedures at the same moment. In some cases the complete reduction 
has only been effected when the patient has been brought under the 
influence of an anaesthetic. 

As to the maintenance of the bone in its socket for a length of time 
sufficient to insure a firm union of the broken tissues, this will be 
found always more difficult, and, in a great majority of cases, abso- 
lutely impossible. Nearly all surgeons who have written upon this 
subject have made the same observation ; and if occasionally a new 
apparatus in the hands of a clever surgeon has seemed to promise 
better results, the same apparatus in the hands of other equally clever 
surgeons, and under circumstances equally favorable, has been found 
almost constantly to fail ; and we have been compelled again to exer- 
cise anew our ingenuity, and to seek for new resources, or to abandon 
the effort in despair. 

Only very lately a surgeon, Dr. Folts, of Boston, believed that he 
had found in Bartlett's apparatus for broken clavicles modified by the 
application of a shoulder-strap, the infallible remedy for this one of 
the many sad defects in our art. The most important part of this 
dressing, according to Dr. Folts, is the compress placed upon the 
upper and outer end of the clavicle, and the bandage or strap passed 
over the compress and under the point of the elbow to maintain it in 
position. 2 

Dr. Folts is no doubt correct in regarding this strap as an import- 
ant if not the essential part of the apparatus ; and it is surprising 
that by Sir Astley Cooper, as well as by many other experienced sur- 
geons, its value should have been overlooked. The chief obstacle to 
the retention of the bone in place is the powerful action of the tra- 
pezius, which constantly tends to elevate the outer end of the bone. 
In some measure this may be resisted by elevating very forcibly 
the shoulder, or by inclining the head, but both of these positions are 
extremely fatiguing, and will not be long endured. The bandage or 
strap, adjusted in the manner which Dr. Folts has recommended, is the 
only means of counteracting the action of the trapezius, upon which 
any substantial reliance can be placed ; but the principle has long been 
understood and practised upon. Bradsor's tourniquet, or Petit's, secured 
by a strap brought under the point of the elbow, Boyer's double shoulder- 

1 Am. Med. Times, Oct. 24, 1863. 

2 Folts, Bost. Med. and Sarg. Journ., vo 1 . liii. p. 259. 



540 



DISLOCATIONS OF THE CLAVICLE. 



straps and Desault's third bandage, all aimed at the accomplishment 
of the same purpose; yet Boyer and Desault found all these con- 
trivances fail in a majority of cases. Mayor employed a dressing 
constructed with a strap to buckle over the dislocated clavicle, but 

ISTelaton has seen this apparatus 



Fig. 222. 



ipplied in his 




Mayor's apparatus for dislocated clavicle. ("Trl 
angle cubito-bis-scapulaire.") 



fail, also, when 
own wards. 

The experience of Dr. Folts 
at the time of his report did not 
extend beyond three cases, and 
the apparatus had been com- 
pletely successful in only two of 
the three. Our own experience 
is sufficient to show that it will 
be found occasionally, but by 
no means constantly, successful. 
We have already mentioned one 
case in which we succeeded per- 
fectly by this mode, but in seve- 
ral others which seemed equally 
favorable we have met with par- 
tial or complete failures. 

The practical difficulties are, 
the sensibility and consequent 
inability sometimes of the point 
of the elbow to bear the requisite 
pressure, and the even greater 
sensibility of the skin over the top of the clavicle; the tendency of the 
bandage to slide off from the shoulder and also to become displaced 
from the end of the elbow ; the gradual relaxation of the bandages, 
which, when existing even in the most inconsiderable degree, is suffi- 
cient sometimes to allow the bone to slip out from its shallow socket ; 
the impossibility of fixing the scapula, upon whose immobility as 
well as upon the immobility of the clavicle the retention depends; and, 
finally, the great length of time requisite to unite firmly the ligaments, 
if indeed they ever again become actually united. 

The band can be prevented in some measure from sliding off from 
the clavicle by a counter-band attached to a collar upon the opposite 
shoulder, but not without causing some pain and giving rise to exco- 
riations generally in the opposite axilla ; and, in a degree, all the other 
difficulties may be met by patience and ingenuity, but unfortunately 
the smallest failure in any one of these numerous indications insures 
a defeat. 

The axillary pad employed as a fulcrum upon which extension may 
be made is equally as dangerous here as in fractures, and I do not 
think it ought ever to be used for this purpose, but only as a means 
of moderate support and retention ; indeed it would be well, perhaps, 
if it were discarded altogether. 

The case of Mr. B., already quoted, with a dislocation outwards and 
backwards, affords not only an illustration of the inefficiency of either 



OF THE AOEOMIAL EXD OF CLAVICLE DOWNWARDS. 541 

the shoulder-strap or the axillary pad in certain cases, but also, it seems 
to me, of the mischief which may result from their too diligent appli- 
cation ; for I cannot persuade myself but that most of the maiming in 
this case was due to the apparatus rather than to the original accident. 

This gentleman was injured on the 10th of November, 1855. A 
sling with an axillary pad and bandages was immediately applied. I 
saw him on the seventeenth day. The displacement was then such as 
I have described, but I did not observe any paralysis or emaciation of 
the limb. Having- noticed that the clavicle fell into its socket when 
he lay upon his back in bed, at my suggestion all the dressings ex- 
cept the sling were removed, and the patient was laid upon his back 
in bed, with instructions to continue in this position, if possible, until 
the cure was completed ; but after a few days I received a communi- 
cation from his physician, stating that, owing to a troublesome cough, 
he had found it impossible to maintain this position. His residence 
was forty or fifty miles from town, and I sent him one of my dressings 
for broken collar-bones with instructions as to its use ; directing espe- 
cially that a shoulder-strap should be used to keep the clavicle down. 

The dressing was applied and continued six weeks, and on being 
removed, the elbow, wrist, and finger joints were found to be stiff. 
The whole arm was emaciated and almost powerless. One year later 
there was no improvement in the condition of the arm ; every joint 
from the shoulder down was almost completely anchylosed, the mus- 
cles were greatly wasted, and the hand trembled constantly. 

These results, it seems to me, were due to too long and too tight 
bandaging of the arm, and especially to the pressure of the axillary 
pad. I do not state this positively, but this is my belief. 

Is it worth while, then, to incur the dangers of too long confinement 
and of excessive bandaging for the purpose of attaining the always 
uncertain result of maintaining the bone in its socket? We certainly 
may be permitted to make the attempt within certain reasonable 
limits; and especially if the patient is a female and the avoidance of 
deformity is a point of serious consideration; but never without keep- 
ing constantly in mind the possibility of a permanent anchylosis and 
paralysis of the limb. 

§ 5. Dislocation or the Acromial End op the Clavicle Downwards. 

This form of dislocation is exceedingly rare, only three well-authen- 
ticated cases having, been placed upon record, one of which was seen 
and dissected by Melle, 1765, the second was met with by Fleury, in 
1816, and the third is described by Tournel. 

Cause. — So far as we can ascertain, it has been produced only by a 
force which has acted directly upon the top of the clavicle. In the 
case mentioned by Tournel, a horse had trod upon the shoulder, and 
in the example recorded by Melle, the accident occurred in a child 
six years old, from an attempt to support a great weight upon the top 
of the collar-bone. In this last example the humerus was dislocated 
also, and both dislocations had remained unreduced many years when 
the patient was seen by Melle. 



542 DISLOCATIONS OF THE CLAVICLE. 

This force acting directly upon the top of the clavicle would fail 
to dislocate the bone, except by first breaking down the coracoid 
process, if it did not happen sometimes that at the same moment the 
lower angle of the scapula was thrown outwards, in such a manner 
as to depress slightly the coracoid process, and thus to permit the 
outer end of the clavicle to fall below the level of the acromion process. 

Symptoms and Pathology. — This dislocation, whether it has been 
produced artificially upon the dead subject or accidentally upon the 
living, has always been found to be accompanied with a complete 
rupture of the acromio-clavicular ligaments not only, but also of the 
coraco-acromial and coraco-clavicular ligaments ; the outer extremity 
of the bone resting between the acromion process and the capsule of 
the shoulder-joint, and a little posterior to the articulating facet which 
originally received the clavicle. 

The superior angle of the scapula approaches the body slightly, 
and its inferior angle is thrown outwards. A marked depression exists 
at the point of dislocation, accompanied with a sharp pain, increased 
especially when an attempt is made to move the arm. The patient is 
unable to lift the arm voluntarily, but it can be moved pretty freely 
in the direction forwards and backwards by the hands of the surgeon : 
abduction is much more difficult. 

Treatment. — Eecluction is easily accomplished. At least, in the only 
two examples upon the living subject in which the attempt has been 
made, it was effected promptly by drawing the shoulders gently out- 
wards and backwards ; nor has it been found any more difficult to 
maintain it in position when once replaced. When the scapula is re- 
stored to its natural position, and its lower angle approaches again the 
side of the body, a reluxation becomes impossible ; since the coracoid 
process now effectually prevents that descent of the clavicle upon which 
its displacement always depends. It is only necessary, therefore, to 
secure the scapula at its base and lower angle snugly to the body, by 
a broad band and compress, and all the indications of treatment are 
completely fulfilled. 

§ 6. Dislocation of the Acromial End of the Clavicle under the 
Coracoid Process. 

Pinjou met with one example of this singular dislocation, 1 and 
Godemer, of Mayenne, has recorded five more, 2 and these constitute 
the whole number which are at this day known to science. 

Cause. — Age and a consequent relaxation of the ligaments seem to 
constitute a predisposing cause, since of the six recorded examples 
four were between the ages of sixty-seven and seventy- one, and the 
other two were adults. In all the cases, also, the dislocation was the 
result of a fall upon the shoulder. 

The symptoms which have been said to characterize this accident 
are pain and a Yerj marked depression at the point of displacement, 

1 Pinjou, Journ. de Med. de Lyon, Juillet, 1842, from Vidal (de Cassis). 

2 Godemer, Recueil des travaux de la Soc. Med. d'Indre et Loire, 1843, from Vidal. 



DISLOCATIONS OF THE SHOULDEK. 543 

with a corresponding projection of the acromion and coracoid pro- 
cesses ; a rapid inclination outwards and downwards of the line of the 
clavicle, its outer extremity being felt in the axilla ; the corresponding 
shoulder depressed and inclined forwards ; freedom of motion in all 
directions except inwards and upwards ; the lower angle of the scapula 
thrown outwards and backwards ; to which Morel-Lavallee has added 
an actual increase of space between the acromion process and the 
sternum. 

Treatment — Godemer reduced all the examples which came under 
his notice easily, by directing an assistant to pull the arm backwards 
and outwards while he himself seized upon the clavicle with his fin- 
gers, and disengaged it from under the process; but Pinjou, after 
many efforts by the same method, failed completely, and the patient 
having left him, the clavicle was reduced the next day by an empiric. 
Yidal (de Cassis) recommends that instead of pulling the arm out- 
wards, by which procedure the pectoralis major is made to antagonize 
the surgeon, the elbow shall be brought down to the side, and kept 
there by the left hand, while the right hand, placed in the axilla, shall 
pull the upper end of the humerus outwards, converting the arm into 
a lever of the third kind. This process, I confess, seems to be much 
the most rational. 

Finally, having given the history of these cases as they have been 
reported, we shall scarcely have performed our duty as a faithful 
writer, if we do not state frankly that we entertain a suspicion that 
both the gentlemen who have reported these curious examples have 
entertained us with fabulous or imaginary stories ; and especially do 
these suspicions rest upon the cases reported by Godemer, who in five 
years saw five cases, each presenting throughout the same class of 
symptoms, the same facility of reduction, accomplished by the same 
means, and always with the same perfect result. 

If to these singular coincidences we add the fact that only one other 
surgeon has ever claimed to have met with the accident, and if we 
notice the actual anatomical difficulties which stand in the way of its 
occurrence, such especially as the complete occlusion of the subcora- 
coidean space by the tendons and muscles which pass from its extre- 
mity toward the chest and arm, we shall find a fair apology for some 
degree of scepticism. 



CHAPTEE VI. 

DISLOCATIONS OF THE SHOULDER (HUMERUS AT 
ITS UPPER EXTREMITY). 

Owing to the great exposure, and the peculiar anatomical structure 
of the shoulder-joint, its structure having reference mainly to freedom 
of motion rather than to firmness and security in the articulation, 
dislocations of the humerus are very common. 



54:4 DISLOCATIONS OF THE SHOULDER. 

Writers have not been agreed as to the precise anatomical relations 
of these dislocations, nor as to the nomenclature. Yelpeau, Malgaigne, 
Yidal (de Cassis), Skey, and Sir Astley Cooper have each adopted 
explanations and classifications peculiar to themselves. With the 
arrangement established by this latter surgeon, English and American 
students are the most familiar ; and believing that it is more simple, 
and quite as appropriate as either of the others, I shall adopt it as the 
basis of my own descriptions. 

I shall have occasion, however, to dissent from the opinions and 
teachings of this distinguished surgeon, as to the exact seat and rela- 
tions of the head of the humerus in some of these dislocations. 

According to Sir Astley Cooper, there are three complete luxations 
of the shoulder, namely, downwards, forwards, and backwards. 

§ 1. Dislocation of thb Shoulder Downwards {Subglenoid). 

This is usually called a dislocation into the axilla ; the head of the 
bone resting rather upon the inner side of the inferior border of the 
scapula, near the base of that triangular surface which is found below 
the glenoid fossa. 

Since in both the other complete dislocations of the shoulder, the 
head of the humerus, in order to escape from its socket, must be made 
to descend more or less downwards, we shall regard this dislocation 
as the type of all the others, and shall make it the subject of especial 
consideration as well as of reference when speaking of the other forms 
of dislocation. 

Causes. — The most frequent cause of this accident is a blow received 
directly upon the upper end and outer surface of the humerus. I have 
found the arm dislocated into the axilla by this cause eleven times ; 
four times by a fall upon the extended hand; once by a fall upon the 
elbow, and in this latter case the arm was probably carried away from 
the body at the moment of the receipt of the injury. 

In all the above examples the shoulder has been dislocated by the 
simple force of the blow, or with only slight aid from muscular action; 
but in a considerable number of cases the bone is displaced almost 
wholly by the action of the muscles, the arm having been previously 
violently abducted ; and perhaps in some cases the capsule being torn 
before the resistance of the overstrained muscles has accomplished the 
displacement. Thus, in three instances I have known the dislocation 
to result from holding on to the reins after being thrown from a car- 
riage; in two cases the patients have fallen through a hatchway and 
been caught and suspended by the arms ; once a woman met with 
this accident by holding on to a pump-handle when she had slipped 
and fallen upon the ice. A few years since I examined the arm of a 
Swiss woman, Maria Norregan, who was then sixty-five years old, and 
whose humerus had been dislocated into the axilla seventeen years 
before, where it still remained. Her own account of the accident was, 
that she was returning from the Jura Mountains, near Neufchatel, with 
a load of hay upon her head. She had carried it a long way with her 
hands held upwards, without once stopping to rest, and when at length 



DISLOCATION OF THE SHOULDER DOWNWARDS. 545 



she threw down the load at her door, the right shoulder was dislocated. 
The arm soon became very painful, and swollen to the fingers' ends ; 
but she was too remote from, and too poor to employ, a surgeon. A 
tailor, who used to do the minor surgery of the neighborhood, bled 
her three or four times, but the dislocation was not recognized until 
many months after. 

A Mrs. Hunn informed me that when she was twenty-two years old 
she had a convulsion, and that her attendants, in trying to hold her 
upon her bed, actually pulled the shoulder out of joint. After the 
first accident the dislocation was not repeated for four years, but since 
then it had occurred from very slight causes many times. She was 
in the habit of reducing it herself by placing a ball in the axilla and 
using the arm as a lever. 

Dr. Lehman reports the case of a sailor on board an American brig, 
who was subject to a dislocation into the axilla from very slight 
causes, and especially if he bent his body far over to raise anything. 
He could also, by pulling horizontally, remove the head of the bone 
from its socket. It was reduced easily, and he experienced no pain 
either in the reduction or dislocation, nor, indeed, during the displace- 
ment. 1 

Pathology. — In this accident the head of the bone is made to press 
against the capsule below and immediately in front of the long head 
of the triceps, until the capsule 



gives way, and continuing to 
descend in the same direction 
it is finally arrested by the 
triangular surface of the in- 
ferior edge of the scapula im- 
mediately below the glenoid 
fossa. Owing to the pressure 
of the tendon of the triceps 
behind, it occupies a position 
also a little in advance of the 
centre of this triangle, or rather 
upon its anterior edge, so that 
it rests more or less upon the 
belly of the subscapularis mus- 
cle. 

The capsule is generally torn 
quite extensively, especially be- 
low and in front; and, the ten- 
don of the long head of the 
biceps may be broken asunder, 
or detached completely from 
its insertion ; the supra-spinatus 
muscle is stretched or lacerated 
coraco-brachialis are put upon 



Fig. 223. 




Dislocation of the shoulder downwards into the ax- 
illa. (Subglenoid.) 



; the infra-spinatus, subscapularis, and 

the stretch; the subscapularis being 

also sometimes completely torn from its attachment to the head of the 



1 Lehman, Amer. Journ. Med. Sci., vol. i. p. 242, 1328. 



5-16 



DISLOCATIONS OF THE SHOULDEE. 



"humerus, and in either case, whether torn or merely compressed and 
stretched, the circumflex nerve, which runs along its lower margin, is 
subject to severe injury; the deltoid muscle is also placed in a condi- 
tion of extreme tension; while the teres major and minor in this 
respect are subjected to but little change. 

In some cases a portion or the whole of the greater tuberosity is 
completely detached, and the fragment displaced by the action of the 
muscles inserted into it. 

Symptoms. — A palpable depression immediately under the extrem- 
ity of the acromion process, more distinct in children, in very old and 
in thin people, than in adults of middle life or than in fat or muscular 
people, but never absent completely, unless the shoulder is very much 
swollen; the elbow carried out from the body three or four inches, 
sometimes a little backwards, and the line of its axis directed toward 
the axilla ; the outer surface of the arm presenting two planes inclined 
toward each other, and meeting at the point of insertion of the deltoid 
muscle; the head of the humerus felt in the axilla, particularly when 
the elbow is carried away from the body; numbness of the arm, 
accompanied generally with pain, especially when any attempt is 
made to press the elbow against the side; rigidity with inability to 
move the arm freely in any direction, but especially inwards ; allowing, 



Fig. 224. 




Dislocation of the shoulder downwards into the axilla. (Subglenoid.) 



however, of pretty free passive motion, but not permitting the elbow 
to touch the body without great pain, which pain is occasioned mostly 
by the pressure of the humerus upon the axillary plexus ; under no 
circumstances can the hand be placed upon the opposite shoulder 



DISLOCATION OF THE SHOULDER DOWNWARDS. 547 

while at the same moment the elbow touches the thorax ; the head of 
the patient, and sometimes the whole body, inclined toward the in- 
jured arm ; the arm lengthened from half an inch to an inch ; a chaf- 
ing or friction sound is not unfrequently present, especially if the bone 
has been some days dislocated ; but Mr. Lawrence mentions a case in 
which there was a distinct crepitus, yet there was no fracture ; Dr. 
Hays saw a similar case in Wills Hospital, Philadelphia, in a woman, 
sixty years old, whose arm had been dislocated forwards eight weeks. 1 
Other surgeons have related like examples, but it is probable that in 
all these cases there has been an exposure of the bone at or near the 
edge of the glenoid fossa, by the partial detachment of its ligamentous 
margin, or some portion of the head has become divested of its car- 
tilaginous covering. (For a more complete differential diagnosis, see 
chapter on fracture of the humerus.) 

Decisive as these signs usually are of the true nature of the accident, 
cases will every now and then occur in which the diagnosis will be 
attended with great difficulty, and especially if a few hours have been 
permitted to elapse since the occurrence of the injury, so that consid- 
erable effusions of blood and of lymph may have taken place ; while 
at a still later period, when the swelling has subsided, the diagnosis 
again becomes easy. " At this latter period," says Sir Astley Cooper, 
"it is that surgeons of the metropolis are usually consulted ; and if we 
detect a dislocation which has been overlooked, it is our duty in can- 
dor to state to the patient that the difficulty of detecting the nature of 
the accident is exceedingly diminished by the cessation of inflamma- 
tion, and the absence of tumefaction." 

It has never happened to me to have seen a case of dislocation into 
the axilla which was not easily recognized, nor have I met with any 
cases in the practice of other surgeons, but in my report to the New 
York State Medical Society, already referred to, I have related two 
cases which were not recognized by the patients themselves, and no 
surgeon was called until after several days or weeks, and three cases 
in which empirics having been employed they failed to detect the dis- 
location. Although, therefore, I am prepared to admit the justness of 
the observations made by Sir Astley Cooper, I think that if the case 
is seen within an hour or two after the accident, its nature may be 
generally determined promptly by the surgeon of ordinary experience ; 
but upon this subject I have already spoken very fully in the chapter 
on fractures of the humerus ; and from the examples and opinions 
which I have there presented it will be inferred that it is much more 
common to mistake a fracture for a dislocation, than a dislocation for 
a fracture, an observation which is equally as applicable to dislocations 
forwards as to the form of dislocation now under consideration. 

Prognosis. — If the force which displaced the bone was not great, or 
if the shoulder-joint has not suffered any injury from the accident 
itself beyond the mere rupture of the capsule and a moderate straining 
of the muscles, and if the dislocation has been early and easily reduced, 
the patient is immediately after the reduction able to move the arm 

1 Lawrence, Hays, Arner. Journ. Med. ScL, vol. xxiv. p. 236, May, 1839. 



548 DISLOCATIONS OF THE SHOULDER. 

freely in all directions: very little swelling follows, and in a short 
time a perfect restoration of all the functions of the limb is accom- 
plished. 

It cannot, however, always be inferred from the degree of violence 
employed in the production of the dislocation, nor from the absence or 
presence of swelling, how much injury the tendons, muscles, and 
nerves have suffered, since the same causes produce greater lesions in 
one person than in another, and the amount of swelling may depend 
upon the accidental rupture of an unimportant bloodvessel, or upon 
some peculiarity in the constitution of the patient predisposing to 
serous, fibrous, or sanguineous effusions. 

To whatever cause we may find occasion to attribute the result, it 
will nevertheless be observed that, in a great majority of cases, the 
limb is not restored to all its original strength and freedom of motion 
until after the lapse of some months ; and the shoulder does not re- 
sume its perfect form and symmetry until a much later period; occa- 
sional pains, especially after exercise of the muscles, and in certain 
conditions of the weather, are present also at irregular intervals and 
for indefinite periods of time. Opposite and more favorable termina- 
tions must be regarded as exceptions to the rule. 

Where the reduction has been made within a few hours, I have 
found the shoulder affected with muscular anchylosis with more or 
less weakness of the arm after a lapse of from a few days to one or 
two years. 

A laborer, aet. 41, had dislocated his right shoulder into the axilla. 
Dr. H., an intelligent young surgeon, reduced the bone easily with his 
hands alone, while the patient was still unconscious from the shock of 
the injury. After six weeks he called upon me, accompanied by his 
surgeon, thinking that it was not properly reduced because the arm 
was still painful, and he could not mova it freely. The bone was, 
however, well in its socket. One year later I examined this man, and 
found some anchylosis remaining in the shoulder-joint. 

James Eogers, set. 39, fell while running and struck upon his right 
shoulder. Dr. Eastman, Prof, of Anatomy in the Buffalo Medical 
College, reduced the dislocation four hours after the occurrence, in 
the following manner: The patient being seated in a chair, Dr. East- 
man placed his knee in the axilla and manipulated, while one assistant 
supported the acromion process, and another pulled downwards upon 
the forearm. The time occupied in the reduction was about two 
minutes, and the bone finally resumed its position with a snap audible 
to all the persons in the room. For some months after, and at the 
period when I was invited to see him, the muscles about the shoulder 
were rigid, and the motions of the joint embarrassed ; but at the end 
of two years, Dr. Eastman informed me that the joint had become free, 
and the arm as useful as before, except that he could not throw a 
stone. 

In another case, a gentleman residing in an adjoining county, aet. 
42. was thrown from his carriage, falling forwards upon his hands. 
The dislocation was reduced promptly, by placing the heel in the 
axilla, and within fifteen minutes after it had occurred. Three months 



DISLOCATION OF THE SHOULDER DOWNWARDS. 549 

after this the patient consulted me on account of the immobility of 
the shoulder-joint, and because several surgeons had expressed a 
doubt whether it was properly reduced. The anchylosis was then so 
complete that the humerus could not be moved separately from the 
scapula, but there was no displacement. This gentleman again called 
upon me at the end of four years, and I then found the arm nearly 
restored to its original condition, but it was not quite so strong as 
before. He experienced also "curious" sensations in his arm and 
hand occasionally. The anchylosis had continued with very little 
improvement about two years, after which it had been gradually dis- 
appearing. 

I need scarcely say that in those examples in which the reduction 
of the bone has been delayed beyond a few hours, or for several days 
or weeks, the continuance of the anchylosis has been more persistent ; 
but in no case which has come under my observation, unless the bone 
still remained unreduced, has the anchylosis been permanent. For 
this reason I am disposed to think that muscular, rather than fibrous 
or ligamentous anchylosis, is the cause, generally, of the immobility 
of the joint. I have certainly never in any instance met with a true 
bony anchylosis as a consequence of a shoulder dislocation. The an- 
chylosis in question seems to be a result simply of laceration or more 
generally of a severe strain of the muscular fibres, resulting in in- 
flammation and a contraction of these fibres ; and its occurrence in 
any particular case may therefore be justly attributable either to the 
position of the bone when it is dislocated, to the force of the blow 
which has produced the dislocation, or to the violence applied in the 
attempts at reduction. 

Paralysis and wasting of the muscles of the arm, either with or 
without muscular contraction and rigidity, are also observed in a cer- 
tain number of cases. Especially has it been noticed that the deltoid 
muscle is liable to atrophy ; and in their attempts to explain the fre- 
quency of its occurrence in this latter muscle, surgeons have generally 
referred to a probable rupture of the circumflex nerve, a circumstance 
which the autopsies show does occasionally take place ; or to a mere 
stretching of this nerve ; yet it is quite as fair to presume that in 
many cases it is due solely to the greater injury which the deltoid 
muscle has sustained by the unnatural position of the head of the 
bone during the continuance of the dislocation, for, with the exception 
of the supra-spinatus, it is placed more upon the stretch than any other. 
Nor is it improbable that in some cases it is due to the mere force of 
the blow which, having been received directly upon the top of the 
shoulder, has contused the muscle. In short, any of the causes which 
may determine in the deltoid inflammation and consequent rigidity, 
must finally result in desuetude and consequent atrophy. 

In quite a number of cases my attention has been called to a re- 
markable fulness just in front of the head of the bone, which has 
continued sometimes for many months and even years after the re- 
duction has been effected, the patients having in several cases applied 
to me to know whether this did not indicate that the bone was not in 
its socket, especially as it has been usually attended with some stiff- 



550 DISLOCATIONS OF THE SHOULDER. 






ness in the joint. Not unfrequently I have been told that surgeons 
who had noticed this fulness,, thought the bone was not reduced ; and 
in one instance I am informed that a jury returned a verdict against 
the surgeon, where there was no other evidence of malpractice than 
this fulness with some anchylosis, but which, in the opinion of these 
gentlemen, was conclusive evidence that the bone was not properly 
set. The deception is also often the more complete from the fact that 
there may exist a corresponding depression underneath the acromion 
process, behind. 

It may be present where but little force has been used, either in the 
production of the dislocation, or in its reduction. I have seen it in a 
girl, only fourteen years of age, who had dislocated her left shoulder 
into the axilla, by a fall upon a slippery side-walk. I reduced the 
bone, assisted by Dr. George Burwell, within half an hour after the 
accident. Dr. Burwell held upon the acromion process while I lifted 
the arm to a right angle with the body, and pulled gently, and the 
reduction was at once accomplished ; but we immediately noticed that 
the head of the bone seemed to press forwards in the socket so as to 
resemble what Sir Astley Cooper has described as a partial forward 
luxation. There was also a corresponding depression behind. Carry- 
ing the elbow back rendered the projection more decided, but bringing 
it forwards would not make it entirely disappear. 

In other instances much more difficulty has been experienced and 
more force has been employed in the reduction. A man weighing 
two hundred pounds, and forty-one years of age, residing at Bath, in 
Steuben Co., fell from a load of hay in May, 1853. striking upon the 
top and front of the left shoulder. It was immediately ascertained 
that he had dislocated his arm into the axilla, and broken his leg. A 
young surgeon attempted within a few minutes to reduce the disloca- 
tion, but failed ; and about two hours later it was reduced by another 
surgeon, with the aid of chloroform and Jarvis's adjuster. Four years 
after the accident had occurred, this gentlemen came to me accom- 
panied by the surgeon who had made the reduction, in consequence 
of its having been intimated by some medical men that it was not 
properly reduced. The arm was not as strong as the other ; some 
anchylosis existed at the shoulder-joint : but especially it was noticed 
that there still remained a remarkable fulness in front, as if the head 
of the bone was pressed forwards. By no manipulation or position 
could this fulness be made to disappear, yet the bone was plainly 
enough in its socket. 

This phenomenon is probably due in some cases to a rupture of the 
supra-spinatus muscle, and the consequent preponderating action of 
the antagonizing muscles, or to the laceration of the capsule, but most 
often, I imagine, to a rupture or to a displacement of the long head of 
the biceps, a circumstance to which I shall more particularly allude 
under the subject of " partial dislocations." 

Among the results of this dislocation must be placed a tendency to 
reluxation, which, although it may not often be made manifest by its 
actual occurrence, owing perhaps to the prudence of the surgeon, yet 
it does take place in a sufficient number of cases to establish its 



DISLOCATION OF THE SHOULDEK DOWNWAKDS. 551 

peculiar liability. Indeed, we need only consider how imperfect is 
the protection against this accident, when once the capsule has been 
torn, to appreciate this observation. Examples of spontaneous luxa- 
tion, or of luxation of the shoulder from very trivial causes, after it 
has once been luxated, may be found in the experience of almost 
everv surgeon. I have myself met with several persons who have 
had a second or third luxation from a slight cause, and in some in- 
stances, where the patients were subject to epilepsy, the luxations 
have occurred whenever the convulsions returned. 

A gentleman residing in Toronto, Canada West, had a dislocation 
of the right shoulder into the axilla when he was quite a child, and 
the accident was renewed when twenty-nine years old by falling from 
a carriage head foremost, with his right arm extended and uplifted. 
Since then until he called upon me, a period of about six years, he 
has been constantly subject to the same dislocation; and he cannot 
raise his arm high above his shoulders without producing a subluxa- 
tion, the head of the humerus resting upon the outer margin of the 
lower and anterior edge of the glenoid fossa, but by rotating the arm 
outwards it immediately resumes its place. I found the whole limb 
as fully developed, and he said it was quite as strong, as the opposite 
limb. 

I have already mentioned the case of Mrs. Hunn, whose arm had 
been dislocated more than twenty times in the last five years ; and I 
remember a lad, Pat. Dolan, aged nineteen years, whose left arm was 
dislocated by falling from the mast-head of a vessel and hanging by 
his hand. No attempt was made to reduce it until fourteen hours 
after the accident, at which time it was set by two German doctors, 
but not until they had pulled upon it three hours. Four months 
after it was again dislocated by the slipping of an oar while he was 
rowing a boat. A surgeon having failed this time to bring it into 
place, I succeeded readily and without the aid of an anaesthetic, by 
raising the arm directly upwards in the line of the body, while my 
foot was pressed upon the top of the scapula. 

We have referred more than once to the occasional difficulty of 
diagnosis in this as well as in many other shoulder accidents ; and I 
have alluded to five cases in which the dislocation was not recognized, 
but none of them had been seen by a surgeon. Other writers have, 
however, mentioned many examples of unreduced dislocations of the 
shoulder, for which surgeons of skill and experience were responsible. 
I have myself met with these cases quite often. During the present 
year I have seen two dislocations of the humerus into the axilla, both 
of which had been seen and examined by New York hospital surgeons 
within a few hours after the receipt of the injury, but the nature of the 
accident had not been recognized. One of these I reduced at Bellevue 
Hospital on the seventh day and one on the tenth. There was also 
presented to me, at the Charity Hospital (Blackwell's Island), in my 
service, an axillary dislocation of twenty years' standing, which a sur- 
geon saw immediately after the receipt of the injury and failed to 
recognize. In other cases the dislocation has been clearly made out, 
but the surgeon has been unable to reduce the bone. It has been my 



552 



DISLOCATIONS OF THE SHOULDER. 



fortune to succeed in several instances where others have made a fair 
trial and have failed, but the following case leaves me no opportunity 
to boast the superiority of my own skill above that of my confreres. 

Mary Kanally, set. 49, a large, fat, laboring woman, was admitted 
into the Buffalo Hospital of the Sisters of Charity, with a dislocation 
of the right humerus into the axilla, which had occurred twelve hours 
before. This is the same woman of whom I have before spoken as 
having produced the dislocation by a fall while holding upon the 
handle of a pump. 

Drs. Lockwood and Baker, of Buffalo, were first called, and attempted 
reduction. They made extension and counter-extension in every 
possible direction, and for a long time, but to no purpose. She was 
then sent to the hospital. Without attempting to describe minutely 
the various modes of extension and manipulation which I employed, 
I will briefly state that, having placed her completely under the influ- 
ence of chloroform, the manipulations were made assiduously during 
one hour, without success. On the following morning she was bled 
freely from the opposite arm, and chloroform again administered ; 
extension being made, in the presence of Prof. Charles A. Lee and 
other gentlemen, with Jar vis's adjuster. After more than an hour, 
the effort was again suspended. On the following day we made a 
third attempt, the patient being completely under the influence of 
chloroform, but with no better success. The chloroform produced a 
condition approaching apoplexy, and it was not again used. On the 
tenth day, assisted by Prof. James P. White and other surgeons, we 
applied the compound pulleys, moving the arm in various directions. 
Twice we thought the reduction was accomplished, but as often as we 
proceeded to examine it attentively we found it was not. If it did 
ever pass into the socket, it was immediately displaced. 

The woman after this refused to submit to any further attempts, and 
she soon left the hospital, nor have I seen or heard from her since. 

Sir Astley Cooper has thus described 
Fi g- 225. the appearances presented on dissection 

of a dislocation which had been long un- 
reduced : " The head of the bone altered 
in its form ; the surface towards the 
scapula being flattened. A complete 
capsular ligament surrounding the head 
of the os humeri. The glenoid cavity 
entirely filled by ligamentous matter, in 
which were suspended small portions of 
bone, which were of new formation, as 
no portion of the scapula or humerus 
was broken. A new cavity formed for 
the head of the os humeri on the in- 
ferior costa of the scapula ; but this 
was shallow, like that from which the 

New socket, in an ancient luxation of DOne had escaped. 

the shoulder downwards. ' (From sir a. When the dislocation into the axilla 
cooper.) remains unreduced, the consequences 




Wp 



DISLOCATION" OF THE SHOULDER DOWNWARDS. 553 

are always sufficiently grave, but they differ very much in degree, in 
character, and in persistence, according as the arm has remained a 
longer or shorter time unreduced, and according to the presence or 
absence of complications. These conditions will be best illustrated by 
a reference to examples. 

Wm. S., a German, get. 51, fell down a flight of steps while intoxi- 
cated, producing a dislocation of the left arm into the axilla. Eleven 
hours after the accident, he was received into the Buffalo Hospital of 
the Sisters of Charity. No attempt had been made to reduce the bone. 
The reduction was effected by myself with tolerable ease, by extending 
the arm perpendicularly above the head, while my foot pressed upon 
the top of the scapula. The head of the humerus could be plainly felt 
in the axilla, approaching the socket, until it seemed to be directly over 
it, when, on lowering the arm, it was found to be reduced. After the 
reduction, the patient could not raise the arm more than eight inches 
from the body. The fingers, hand, and forearm were almost paralyzed. 
Three weeks later, when he left the hospital, his arm had improved, 
but he could not flex his fingers. 

Mrs. Gr., get. 70, fell down a flight of steps, and dislocated her arm 
into the axilla. She did not suspect the nature of the injury, and no 
surgeon was called. I was consulted one week after the accident, at 
which time she was suffering great pain from the pressure of the head 
of the bone upon the axillary nerves. We first attempted to reduce 
the bone by resting the knee in the axilla while she was sitting, but 
without success. We then placed her in bed, and with my knee in 
the axilla, the acromion process being supported by the hands of an 
assistant, we restored the bone after a few moments of pretty firm ex- 
tension downwards and outwards. After the reduction she could not 
raise her arm, but the pain was much abated. One month later, the 
arm remained very weak. She could not raise it more than six inches 
toward her head, but I could raise it to a right angle with the body 
without causing pain. The whole hand felt numb, and was occasion- 
ally painful. The deltoid muscle was slightly atrophied. There was 
also a slight flatness under the acromion process behind, and on the 
outer side, with a corresponding fulness in front. 

Mary Ann Hasler, get. 47, was admitted to the hospital, with a dis- 
location of the right humerus into the axilla. The arm had been 
dislocated three weeks, in consequence of a fall upon the upper and 
outer part of the shoulder. An empiric, who saw it fifteen minutes 
after the fall, and when the arm was not swollen, said it was not dis- 
located. On the fifth day, a Catholic clergyman discovered that it 
was out, and attempted to reduce it, but was not successful. When 
she came under my notice, the arm was lengthened about one-quarter 
or one-half of an inch, and hung out from the body in a condition of 
almost complete paralysis. There was very little swelling about the 
shoulder or arm, and the head of the bone could be distinctly felt in 
the axilla. The patient being rendered partially insensible by chloro- 
form, I placed my heel in the axilla, and by pulling moderately about 
thirty seconds in a direction slightly outwards from the line of the 
body, the bone was reduced. Seven days after the reduction, she left 
36 



554 DISLOCATIONS OF THE SHOULDEK. 

the hospital, the arm being yet quite useless, though not greatly- 
swollen. There was also a striking fulness in front of the head of 
the bone. 

Wm. Gardner, of Painted Post, N. Y., get. 75, dislocated the right 
humerus into the axilla twenty years before I saw him, by falling 
upon his hands with his arms extended. I found the arm weak and 
atrophied, so that he could raise it but slightly outwards from his 
side ; he was unable to move it forwards much beyond the line of his 
body, but he could carry it back quite freely. The whole hand was 
in a condition of partial insensibility. 

I have before mentioned the case of Maria Norrigan, the Swiss 
woman, whose arm had been dislocated downwards seventeen years. 
The deltoid muscle has become greatly wasted ; the head of the bone 
can be felt obscurely in the axilla ; the arm is shortened perceptibly ; 
the elbow hangs freely against the side ; the little and ring fingers are 
numb, and also one- half of the forearm ; the whole hand and arm are 
weak and atrophied ; she complains also occasionally of a troublesome 
sensation of formication over the arm and hand ; she cannot straighten 
her fingers perfectly ; the elbow may be raised from the side to a right 
angle with the body, but she cannot raise it herself more than one 
foot ; she carries it back a little more freely than forwards. 

In compound dislocations, the prognosis must always be regarded 
as exceedingly grave. In the only example which has come under 
my notice, the circumstances attending which I shall hereafter men- 
tion in the general chapter devoted to compound dislocations, the 
patient died from sloughing of the axillary artery. Mr. Scott has, 
however, reported a case, in a boy fourteen years of age, who recovered 
rapidly after the reduction was effected, and in thirteen months his 
arm was nearly as useful as before. 1 

Treatment. — The principles of treatment in this dislocation are very 
simple and easy to be comprehended. I speak now of recent uncom- 
plicated cases of dislocation into the axilla ; and, notwithstanding the 
various and sometimes almost contradictory views which surgeons 
have entertained as to the best and most rational modes of procedure, 
I continue to affirm that the laws which are to govern the reduction 
in a great majority of cases are established and indisputable. 

Observe now the obvious anatomical facts, and then consider the 
inevitable inferences. 

The capsule is torn, generally extensively, along the inner and 
lower margins of the socket. The head of the bone is lodged below 
and slightly in advance of its natural position, in consequence of 
which the points of origin and insertion of the deltoid muscle and the 
supra-spinatus are separated somewhat and their fibres rendered tense, 
insomuch that the arm is abducted and actually lengthened. 

At first, and in the most simple cases, these are the only muscles 
which are in a state of extreme tension, but after the lapse of a few 
hours, or of a few days, nearly all the other muscles about the joint, 

1 Scott, Amer. Journ. of Med. Sci., vol. xx. p. 515, Aug. 1837, from the London 
Lancet for March 4, 1837. 



DISLOCATION OF THE SHOULDEE DOWNWARDS. 555 

most of which were originally only in a condition of moderate exten- 
sion, and some of which were rather relaxed than extended, sym- 
pathize with those which are suffering the most, and a general con- 
traction and rigidity ensue, increased also at the last by the superven- 
tion of inflammation and its consequences. 

What, from these simple premises, must be the obvious practical 
deductions ? 

That in the simplest forms of the dislocation the most rational mode 
of reduction will be to elevate the arm sufficiently to relax the over- 
strained deltoid and supra-spinatus muscles, which bind the head of 
the bone in its new position, and to pull gently in the same direction, 
in order to overcome the moderate resistance offered by several other 
muscles, but whose tension cannot be relieved by the same manoeuvre. 

Failing in this, that we shall increase the relaxation of the first 
named muscles, by pulling at a right angle with the body, or even 
directly upwards; and meanwhile, as we carry the arm more and 
more upwards, we shall operate more powerfully against the resistance 
of the other muscles. 

If in all these modifications of the same procedure, we keep the arm 
a little back of the axis of the body, we shall accomplish the indica- 
tions the most perfectly. 

Such are the conclusions which must be drawn from the anatomical, 
or, as Mr. Pott would call it, the "physiological," argument ; and which 
assumes as its basis that the muscles constitute the sole or the main 
obstacle to the return of the bone to its socket. If any surgeon main- 
tains that the premise is unsound, and that the restoration of the head 
of the bone is opposed by the untorn fibres of the capsule or by any 
other important circumstance than the action of the muscles (we speak 
of ordinary cases), we shall content ourselves by referring him again 
to. the extensive laceration which this capsule generally suffers, and 
to the constrained and almost uniform position of the arm, as a suffi- 
cient reply to his objection. 

It must not be forgotten that in all these modes of extension, for 
with nearly all of them some slight degree of extension is found neces- 
sary, there must be afforded some point of resistance beyond the bone; 
and this it is really which has constituted one of the greatest impedi- 
ments to reduction. It is not that the muscles are in such an extra- 
ordinary state of extension or rigidity that they must be operated 
against with great force ; it is not that the margin of the glenoid fossa 
is an elevated barrier, like the margin of the acetabulum, over which 
the bone must be lifted before it can fall into its socket ; but the ex- 
planation of the difficulty so often experienced in producing effective 
extension and counter-extension is to be sought for mainly in the 
fact that the scapula, upon which the humerus rests, is movable, being 
held to the body by little else than muscles, which, in fact, bind the 
scapula much less firmly to the body than the muscles of the shoulder 
now bind the scapula to the arm ; while at the same time the scapula 
itself presents very few points against which a counter-extending force 
can be properly and efficiently applied. 

Occasionally it will be only necessary to elevate the arm to an acute 



556 DISLOCATIONS OF THE SHOULDER. 

angle, or to a right angle with the body, when, the resistance of the 
deltoid and supra-spinatus being overcome, the bone will at once re- 
sume its place. In several instances which have come under my notice 
nothing more has been necessary ; and where it can be done, the least 
possible pain and injury are inflicted. It is the method, therefore, 
which in all recent cases I have first tried and would wish to recom- 
mend. By it I have more than once succeeded when other and more 
violent efforts had failed. 

At other times it will be necessary to add to this simple manipula- 
tion only a moderate degree of extension, such as the hands of the 
surgeon can make, without the application of direct counter-extension 
except what is effected by the weight and resistance of the body. 

If, however, the bone refuses to move, we shall then be obliged to 
consider upon what point and by what means we can best apply a 
counter-extending force. Ample experience has taught me that the 
extremity of the acromion process is the only available point when 
we are making the extension in a line below a right angle, or in a 
line downwards more or less approaching the axis of the body. It 
has been supposed that the counter-extension could be made in the 
axilla against the inferior margin of the scapula ; but several obstacles 
are presented to the successful application of force at this point. The 
axillary space is narrow and deep, so that even with the ingenious 
contrivance of placing first a ball of yarn in the axilla, and upon this 
the heel of the operator, it will be found exceedingly difficult to enter 
the axilla without at the same time pressing with considerable force 
against its muscular margins ; but to press upon the pectoralis major 
and latissimus dorsi is to neutralize our own efforts. If, however, 
the heel or the ball does press fairly into the axilla, it will not find 
the scapula readily, but it must impinge first upon the head of the 
humerus, which is always a little to the inner side of the scapula. If 
it ever is made to reach actually the inferior border of the scapula, 
and I do not think it is, the effect must be still only to tilt the scapula 
upon itself by throwing back its lower angle, and not to separate the 
glenoid cavity or its upper and anterior margin from the head of the 
humerus. 

Whatever success, therefore, may have attended this mode of prac- 
tice, either in my own hands or in the hands of other surgeons, must 
be ascribed not to the counter-extension thus effected, but simply to 
the operation of the heel as a wedge, which, by insinuating itself be- 
tween the body and the head of the bone, has thrust it outwards and 
upwards into its socket ; or to its having acted as a fulcrum upon 
which the humerus has operated as a lever. 

It is to the extremity of the acromion process, then, that we must 
apply our counter-extension when we are employing this mode of ex- 
tension. The fingers or hands of a faithful assistant may answer the 
purpose, or having removed his boot, the operator may often press 
successfully with the ball of his foot, and the more he carries the arm 
outwards the more secure will be his seat upon the process ; or we 
may adopt some of the contrivances for securing the process which 
have been suggested by other surgeons ; such as a band crossing the 



DISLOCATION OF THE HUMERUS DOWNWARDS, 



557 



shoulder, and made fast to a counter-band, which passes through the 
armpit and against the side of the body. Dr. Physick, of Philadelphia, 
reduced a dislocation in this way as early as the year 1790, in the 
case of a patient admitted to St. George's Hospital, in London, while 
he was a student of medicine, and he subsequently taught the same 
in his lectures. Physick directed that an assistant should press firmly 
against the process with the palm of his hand. Dorsey and Hays ap- 
prove of the same method/ and perhaps a majority of American sur- 
geons regard it favorably. 

If we pull directly outwards, at a right angle with the body, we 
may still continue to press upon the acromion process with the foot ; 
or we may perhaps trust to the method of making counter-extension 
first suggested by Nathan Smith, of New Haven. 

Dr. Smith exclaims: "What surgeon of experience has not en- 
countered the difficulty which almost always occurs in fixing the 
scapula?" and then proceeds to explain how difficult it has been 
found to hold securely even upon the acromion process by either the 

Fig. 226. 




N. K. Smith's method. 



fingers of an assistant or the split band, and concludes by stating 
what seems to him the most effectual mode of rendering the scapula 

1 Physick, Amer. Journ. Med. Sci., vol. xix. p. 386, Feb. 1837. Dorset's Elements 
of Surgery, vol. i. p. 214. Philadelphia, 1813. 



558 DISLOCATIONS OF THE SHOULDER. 

immovable, namely, to make the counter-extension from the opposite 
wrist. By this method the trapezii are provoked to contraction, and 
the scapula of the injured side is drawn firmly toward the spine and 
the opposite scapula. In illustration of the value of this procedure 
he relates the case of a gentleman who had suffered a dislocation of 
his left shoulder, and upon whom an unsuccessful attempt at reduc- 
tion had already been made by a respectable surgeon. Dr. Smith 
being called, proceeded as follows : Two gentlemen made counter- 
extension from the opposite wrist, while Dr. Smith and Dr. Knapp 
made extension from the wrist of the injured side, at first pulling it 
downwards, but gradually raising it to the horizontal direction, and 
then gently depressing the wrist. On the effort being steadily con- 
tinued for two or three minutes, the bone was observed to slip easily 
into its place. This gentleman subsequently informed Dr. Smith that 
this procedure gave him much less pain than that adopted by the 
first surgeon. 1 

The same method has been practised and recommended by the son 
of Nathan Smith, Prof. Nathan E. Smith, of Baltimore. 2 

But no position places the scapula so completely under our control 
as that in which the arm is carried almost directly upwards and the 
foot is placed upon the top of the scapula. By this method we may 
succeed generally when every other expedient has failed, yet it is 
painful, and I cannot but think that it increases the laceration of the 
capsule, and does sometimes serious injury to the muscles about the 
joint. La Mothe was the first to recommend this method, 3 but as 
early as the year 1764, Charles White, of Manchester, made fast a set 
of pulleys in the ceiling, and, placing a band around the wrist of the 

Fig. 227. 




La Mothe's method, modified. 

dislocated arm, he drew the patient up until the whole body was sus- 
pended. No pressure, however, was made upon the scapula from 

1 Nathan Smith, Med. and Surg. Memoirs, 1831, p. 337. 

2 Nathan R. Smith, Amer. Journ. Med. Sci., July, 1861. 

3 La Mothe, Amer. Journ. Med. Sci., vol. xix. p. 387, Nov. 1836, from Melanges de 
Med. et Chir., Paris, 1812. 



DISLOCATION OF THE HUMERUS DOWNWARDS 



559 



above, which is no doubt the most essential part of the process. 1 By 
La Mothe's plan, Jobert succeeded after twenty-three days when ail 
the usual methods had failed. 2 Sometimes this procedure is modified 
by placing the hand of the operator against the top of the scapula, as 
is shown in the accompanying drawing (Fig. 227). 

A gentle movement backwards or forwards, a slight rotation of the 
limb, or suddenly dropping the arm toward the body, diverting the 
attention of the patient, are little tricks of the operator, which now 
and then prove successful. ■ 

Sir Astley Cooper thus describes his method of applying the heel 
to the axilla (Fig. 228):— 

Fig. 228. 



OH* 


■2^^*SEil) "" fln#fev «»*>* 


jpF 


^iiiii mm 


" ___w 


--=•■— ~ — "^^b^ 



Sir Astley Cooper's method of applying extension with the heel in the axilla. 

" The patient should be placed in the recumbent posture upon a 
table or sofa, near to the edge of which he is to be brought ; the sur- 
geon then binds a wetted roller around the arm immediately above 
the elbow, upon which he ties a handkerchief; then he separates the 
patient's elbow from his side, and, with one foot resting upon the 
floor, he places the heel of his other foot in the axilla, receiving the 
head of the os humeri upon it, whilst he is himself in the sitting pos- 
ture by the patient's side. He then draws the arm by means of the 
handkerchief, steadily, for three or four minutes, when, under common 
circumstances, the head of the bone is easily replaced; but if more 
force be required, the handkerchief may be changed for a long towel, 
by which several persons may pull, the surgeon's heel still remaining 
in the axilla. I generally bend the forearm nearly at right angles 
with the os humeri, because it relaxes the biceps, and consequently 
diminishes its resistance." 

He was also accustomed in some cases to reduce the dislocation by 
substituting the knee for the heel. Placing the patient upon a low 
chair, the axilla is laid over the knee of the operator, and while one 

1 C. White, Amer. Journ. Med. Soi., Nov. 1836, from Med. Obs. and Inquiries, vol. 
ii. p. 273, London, 1764. 

2 Ibid., vol. xxiii. p. 237, Nov. 1838. 



560 



DISLOCATIONS OF THE SHOULDEE. 



Fig. 229. 



hand steadies the acromion process and scapula, the other presses 
downwards upon the lower end of the humerus (Fig. 229). 

If some hours or days have elapsed since the occurrence of the 

dislocation, it will be necessary to re- 
sort to chloroform or ether for the 
purpose of paralyzing the muscles, 
as well as with the view of prevent- 
ing pain, and it may be necessary, in 
addition, to resort to pulleys, or to 
some similar permanent mode of ex- 
tension. The same measures also 
sometimes become necessary in very 
recent cases, especially in muscular 
subjects. 

In employing the pulleys we gener- 
ally operate not exactly in a line with 
the axis of the body, nor at more than 
a right angle, but between an angle of 
45° and a right angle. 

Mr. Skey has suggested a plan by 
which we may combine the principle 
of the heel in the axilla with the pul- 
leys, but which plan would, in my 
judgment, be very much improved 
by a counter-extending force applied 
to the acromion process. I ought to 
say, however, that Mr. Skey prefers that the scapula should not be 
fixed, believing that the reduction is much more easily effected when 
tbe glenoid cavity is drawn downwards in the act of making the 
extension. 

With all respect for the opinion of this distinguished surgeon, we 
cannot precisely agree with him, and while we would be disposed to 
recommend in some cases a trial of his method of applying the pul- 
leys, we would at the same time, or certainly in the event of its failure, 
add the acromial support, and especially would we advise that the 
arm should be more abducted. The following is Mr. Skey's method, 
as described by himself: — 

"There is no reason why, in very muscular subjects, or in old 
dislocations, the same principle may not be applied conjointly with 




Sir Astley Cooper's method of operating 
with the knee in the axilla. 



Fig. 230. 




Iron knob employed by Skey, instead of the heel. 



the use of pulleys. For the purpose of retaining this admirable, 
because most efficient principle, I employ a well-padded iron knob, 
which may represent the heel, from which there extend laterally two 



DISLOCATION OF THE HUMERUS DOWNWARDS 



561 



strong straight branches of the same metal, each ending in a bulb 
or ring of about four inches in length, the office of which is designed 
to keep the margins of the axilla as free from pressure as possible." 
The iron knob is to be pressed well up into the axilla and attached to 
cords fastened to a staple ; the patient lying upon his back or inclined 
a little to the opposite side. The arm is then to be drawn downwards 
by the pulleys, " as nearly as possible parallel to, and in contact with, 
the body." 1 

In this way Mr. Skey says that he has succeeded in reducing a 
great many dislocations, whether occurring in very muscular men, or 
after some days', or weeks', or even months' duration ; and he thinks 
the plan especially applicable to cases which require long and per- 
sistent extension. 

Fig. 231. 




Skey's method of making extension and counter-extension with pulleys. 



Mr. Skey and many other surgeons prefer to make the extension 
from the hand. I have succeeded as well, and it has seemed to be 
less painful to my patients, when I have followed the practice of Sir 
Astley, and made the extension from the arm. Sir Astley always 
made the extension more or less out from the line of the body, and 
generally almost at a right angle when using the pulleys, the scapula 
being made fast by " a girt buckled on the top of the acromion," or by 
a split cloth (Fig. 232). 

The instrument invented by Dr. Jarvis, of Portland, Conn., called the 
adjuster, useless and even mischievous as we have found it in its appli- 
cation to the treatment of fractures, possesses considerable merit as an 
apparatus for reducing old dislocations, especially of the shoulder. The 
principal advantage which may be claimed for it is, that while the forces 
are being applied the limb may be moved pretty freely in all direc- 
tions ; thus enabling us to employ rotation at the same time that the 
extension is made. We may also lift or depress, adduct or abduct 
the limb without relaxing the extension. In the hands of American 
surgeons it has occasionally been successful when other means have 
failed. Dr. Jarvis has related a case presented at the Marine Hos- 
pital, at Mobile, Tenn., of forty-two days' standing, which he reduced 

1 Skey, Operative Surgery, Arner. ed., p. 93. 



562 



DISLOCATIONS OF THE SHOULDER, 



on the second attempt, after other means had failed -, 1 and Dr. May, of 
Washington, reduced a similar dislocation at the end of six weeks, 



Fig. 232. 




Sir Astley Cooper's mode of making extension with pulleys. 



by the same apparatus, without, however, having previously resorted 
to any other means. 2 

I have myself used the apparatus occasionally, both in my hospital 
and private practice, and can speak favorably of its operation. 

I must not omit to mention the practice adopted by Prof. H. H. 
Smith, of Philadelphia, according to whom nearly all dislocations of 
the shoulder, of a recent date, may be promptly and easily reduced 
by manipulation alone. His method consists, first, in flexing the fore- 
arm upon the arm, while, at the same moment, the elbow is lifted from 
the body ; second, in rotating the humerus upwards and outwards, 
employing the forearm as a lever ; and third, in reversing this last 
movement, that is, rotating the humerus downwards and inwards, while 
at the same moment the elbow is carried again to the side. 3 

When the dislocation is into the axilla this manoeuvre will generally 
succeed ; but if the head of the humerus has slipped forwards, even 
only sufficient to engage itself slightly under the tendons of the 
coraco-brachialis and biceps, the outward rotation of the humerus 
will inevitably thrust the head further forward, and fasten it more 
certainly underneath these tendons ; while the rotation of the humerus 
in the opposite direction will alone often be sufficient to carry the 
head directly into the socket. 

Ancient Luxations. — Finally, I ought to speak somewhat more in 
detail of the manner of procedure and of the principles involved in 

1 Boston Med. and Surg. Journ., vol. xxxix. p. 215. 

2 Boston Med. and Sure. Journ., vol. xxxv. p. 454. 

3 H. H. Smith, Gross's Surg., ed. of 1863, p. 152. 



DISLOCATION OF THE HUMERUS DOWNWARDS. 563 

the reduction of old dislocations, or of dislocations requiring the inter- 
position of mechanical appliances ; especially with a view to the more 
complete exposition of my own practice in these cases. 

If the dislocation is recent, but reduction is found impossible with- 
out the aid of mechanical apparatus, the difficulty will be understood 
to consist mainly, if not altogether, in the resistance offered by the 
muscles. If, in a few exceptional cases, the capsule, or an untorn 
tendon, or the margin of the glenoid fossa, present themselves as 
obstacles, they must still be considered as unusual and extraordinary 
impediments, the existence of which may be regarded rather as pos- 
sible than probable. 

Almost our sole purpose, then, it will be understood, in all recent 
cases requiring mechanical appliances, and in some ancient cases, is to 
overcome the contraction of the muscles. 

We prefer always to place the patient upon a mattress laid upon 
the floor ; two silk handkerchiefs, or two pieces of a cotton roller, are 
then laid along the radial and ulnar sides of the humerus, and over 
the middle of these, immediately above the condyles, a wetted roller 
is applied, its end being made fast with a needle and thread rather 
than with a pin. The upper ends of the longitudinal strips, or of the 
handkerchiefs, are now turned down and tied to the opposite ends, 
thus converting them both into lateral loops. For the purpose of 
making counter-extension, a sheet is passed around the body under 
the axilla, and made fast to a staple ; while an intelligent assistant is 
to manage the scapula with his naked hands, either by pulling with 
his fingers placed under the process, or by pushing with the palm of 
his hand and ball of his thumb. The pulleys, secured to a staple 
exactly opposite to that which holds the counter-extending band, are 
made ready, but not for the present attached to the arm. 

As soon as the patient is placed completely under the influence of 
an anaesthetic, the operator is ready to proceed with the reduction. 
It is my maxim never to attempt to accomplish by complicated and 
violent measures what may be done as well by more simple and 
gentle means. I think it proper, therefore, to make several attempts 
at reduction by manipulation alone, aided now by the anaesthetic, the 
extending and counter-extending bands, &c, before resorting to the 
pulleys. Seating himself upon the mattress, with his boots drawn, the 
surgeon should bend the forearm to a right angle with the arm, and 
planting one heel in the axilla, with one hand he should seize upon 
the loops at the elbow, and with the other steady the hand and fore- 
arm of the patient, while he proceeds to make firm traction for a few 
seconds in the line of the body, or only a little out from this line. 
Failing in this, he may direct the assistant to seize upon the scapula, 
and make counter-extension ; still not succeeding, he may change his 
foot from the axillaUo the acromion process and pull directly outwards 
at a right angle with the body, or he may swing himself gradually 
around until he comes to be above the head of the patient, and the 
foot presses firmly upon the top of the scapula ; now descending again 
in the same direction, he will very probably find the limb reduced, or 
capable of being reduced easily, by operating upon it as a lever by 



564 DISLOCATIONS OF THE SHOULDER. 

laying it across the body while at the same moment it is rotated 
slightly outwards. 

If still the reduction is not accomplished, the pulleys must at once 
be put in requisition. The sheet passed around the chest and fastened 
to a staple, is only a means of supporting the body and rendering it 
more steady ; as a means of counter-extension its value is inconsider- 
able. To make fast the scapula, we must still rely mainly upon the 
naked hands of strong men or upon a strap drawn firmly across the 
process and held in place by an assistant. 

It must be constantly borne in mind that we intend to conquer the 
muscles by fatiguing them, and that this cannot be done by a force 
suddenly applied, however great it may be, but only by gentle, steady, 
and long-continued extension. The muscles, when attacked openly 
and vigorously, resist, and will suffer laceration rather than yield, while, 
on the other hand, an insidious but persevering approach seldom 
fails to end in their defeat. The forearm is again flexed, and the arm 
carried out to a right angle with the body, the pulleys secured to the 
loops, and the assistant takes hold upon the process, while the surgeon 
draws gently upon the rope attached to the pulleys ; as soon as every- 
thing is moderately tense, he is to desist for a few moments. Again 
the rope is drawn upon gently, and again the progress of the extension 
is suspended. In this way the operator is to proceed during half an 
hour, or two hours, as the nature of the case may demand ; occasion- 
ally rotating the humerus, and occasionally lifting its head toward the 
socket. Meanwhile, it is understood that the principal counter-ex- 
tension is made by the assistants, who must relieve each other, at the 
acromion process. The sheet in the axilla, or rather against the side 
of the chest, has some value in this respect when the arm is at a right 
angle with the body, but in itself it cannot control the scapula, only as 
it holds the body to which the scapula is attached. Much, therefore, 
as we may regret the inconvenience of making counter-extension by 
hands alone, experience and anatomy alike must teach that here it is 
the only mode. If these dislocations are reduced often by other 
methods, as no doubt they are, then it is only an evidence that in 
these examples little or no counter-extension was necessary. 

Sometimes the dislocation is not reduced when the extension is 
given up, but if then a resort is promptly made to some one of the 
simple methods already described, while the muscles are still ex- 
hausted, it very often happens that the reduction is easily accom- 
plished. 

It will be prudent in all cases, in order to prevent a reluxation, 
whether the dislocation is recent or ancient, as soon as its reduction 
is effected, to place the arm in a sling and secure the elbow to the side 
by a few turns of a roller. I do not think the axillary pad necessary, 
and I am afraid it has sometimes done as much mischief as the dislo- 
cation itself. 

The following examples will illustrate the variety of expedients to 
which we are obliged sometimes to resort before our efforts prove 
successful : — 

Thomas Leeding, of Niagara Co., K Y., set. 52, a laborer, and a 



DISLOCATION OF THE HUMERUS DOWNWARDS. 565 

muscular man, dislocated his right arm into the axilla, by jumping 
from the cars when they were in full motion. The blow was received 
upon the shoulder. An intelligent country surgeon, assisted by 
several other persons, attempted reduction within an hour after the 
accideut, but failed, and as the patient had some distance to travel, he 
was not brought under my notice until eighteen hours had elapsed. 
We first administered chloroform, and then, while an assistant held 
firmly upon the acromion process, I pulled in the line of the body, 
then outwards, and finally upwards, but to no purpose. Having then 
applied Jarvis's "adjuster," and after the arm had been kept extended 
at a right angle with the body fifteen minutes, we removed the appa- 
ratus, and found the bone in its place. 

John Harrington, set. 50, a very large and powerful man, fell while 
intoxicated, and dislocated his left humerus into the axilla. No sur- 
geon was called until the tenth day, when he first consulted Dr. Dud- 
ley, who at once brought him to me. Without delay w T e applied the 
pulleys, and placing the arm at a right angle with the body, we made 
extension fifteen minutes ; occasionally also rotating the arm. We 
then removed the pulleys, and while an assistant held upon the acro- 
mion process, with my heel in the axilla I made extension in the line 
of the axis of the body, then outwards, and finally upwards with my 
foot upon the top of the scapula. I next seated my patient in a chair, 
and drew his arm and axilla forcibly over my knee. The bone was 
not yet reduced ; I therefore bled him twenty-four ounces, or until 
partial syncope was induced, and proceeded to repeat most of these 
processes, but with no better result. At this moment I determined 
to use sulphuric ether, which had just been introduced as an anaesthetic, 
and while he was completely under its influence the pulleys were 
again applied, and the extension continued for some time, and until 
the rope broke. He was then again placed in a chair, and the axilla 
brought over my knee, when in a moment the reduction was accom- 
plished. 

John Bowles, of Buffalo, aged 45 years, an Irish laborer, tolerably 
muscular, but spare. Bowles fell down a flight of stairs, and dislo- 
cated his left humerus into the axilla. The shoulder became much 
swollen, and was very painful, but he did not suspect a dislocation, 
and did not consult a surgeon. Eight weeks after the accident he 
applied to me. There were present the usual signs of this dislocation, 
but the arm was by careful measurement one inch and a half longer 
than the other. 

The reduction was accomplished on the same day, in presence of 
Drs. Lee, Webster, Coventry, Ford, and Jewett. The time occupied 
in the reduction was about two hours. An attempt was first made 
with the heel in the axilla and with violent rotation and extension. 
The same plan was repeated with the aid of ether, which was adminis- 
tered freely. Jarvis's adjuster was now applied, with no result, except 
that, either in consequence of the force employed by the adjuster, or in 
consequence of the free use of ether, or of both, he became convulsed 
violently, which was accompanied by frothing at the mouth, and other 
grave symptoms. The adjuster was removed, and the exhibition of 



566 DISLOCATIONS OF THE SHOULDER. 

ether discontinued. As soon as the convulsions ceased, and before 
consciousness had returned, extension, rotation, &c, were again made 
by hands. Finally, after all extension was relinquished, placing mj 
knee in the axilla I reduced the bone by a very slight rotary action 
upon the arm. The bone was at once plainly in its socket, but the 
unusual length of the limb continued, being one inch and a half 
longer, though it could be shortened to the same length as the other 
by lifting the elbow. A pad was placed in the axilla, and the arm 
secured with a sling and roller. The next day the arm remained in 
place, but it was now only one inch longer than the other. At the 
end of a fortnight it was only three-quarters of an inch longer, and 
could be reduced to the same length by lifting; the pain and swelling 
about the shoulder, which never were great, were subsiding, and the 
patient was dismissed. 

However skilfully our efforts may be directed, they will be found 
occasionally to fail ; either owing to adhesions which have taken place 
between the head of the bone, or rather its capsule, and the adjacent 
tendons, muscles, etc., to some extraordinary position of the head and 
neck of the bone in its relation to ligamentous or tendinous structures, 
to a filling up of the glenoid fossa, or to some other cause not fully 
explained. Such failures have happened not only in the hands of 
ignorant and unskilful surgeons, destitute of appliances, but also in the 
hands of those who are the most expert, and who are the most com- 
pletely provided with all the necessary apparatus. Indeed, if the truth 
were known, it would probably be found that the number of failures 
has been greater than the successes. The records of surgery, however, 
furnish a great many examples of ancient dislocations of the humerus 
reduced after periods ranging from one month to six, or even longer. 
Dieffenbach has been able to accomplish the reduction of a forward 
dislocation after two years, but not until he had cut the tendons of 
the pectoralis major, latissimus dorsi, teres major, and teres minor, and 
had divided the ligaments surrounding the new joint. 1 

It would be unjust to the young surgeon not to call especial atten- 
tion to the numerous examples of serious and even fatal accidents 
which have followed upon the attempts to reduce ancient luxations at 
this joint. My friend, Greorge C. Blackman, of Cincinnati, a distin- 
guished surgeon, having recently met with one of these unfortunate 
accidents in his own practice, has had the candor to make a public 
statement of the case and of the circumstances which attended it. In 
a letter to the editor of the Western Lancet, published in the November 
number for 1856, he writes as follows: — 

" About the 10th ult., aided by yourself, I succeeded in reducing by 
manipulation, without the pulleys, a dislocation into the axilla, of 
eighty days' standing. The reduction was accomplished in a very few 
minutes, under the influence of chloroform and ether, and the next 
morning the patient left for the country, in a comfortable condition. 
Since that I have received no tidings from him. Encouraged by the 
result in this case, another patient, himself a physician, a tall, athletic 

1 Dieffenbach, Bost. Med. and Surg. Journ., vol. xxii. p. 382, from Medicin. Zeitung. 



DISLOCATION OF THE HUMEKUS DOWNWARDS. 567 

man, and about fifty years of age, decided to submit to the same mani- 
pulation, although his arm had been dislocated for about sixteen weeks. 
The dislocation was downwards and inwards, and about the tenth week 
an unsuccessful attempt, by another surgeon, had been made with the 
pulleys, to which the force of six men was applied for two and a half 
hours. The patient being under the influence of chloroform and ether, 
aided by yourself, Drs. Fries, Cary, Graham, and Kauffman, I com- 
menced my manipulations, adducting, rotating, abducting, and elevat- 
ing the arm. These efforts had been made for about ten minutes, and 
the least possible violence employed, when a tumefaction appeared in 
the pectoral region, which in a few minutes attained a considerable 
size. Supposing that the axillary artery was ruptured, as no pulse 
could be felt at the wrist, a ligature was immediately applied to the 
vessel at the upper part of its course. The operation was performed 
about 10 o'clock A. M., and compression of the pectoral region made 
by means of a sponge and broad roller. On removing this the next 
morning, the tumefaction had nearly disappeared. The patient con- 
tinued comfortable, and about nine days after the application of the 
ligature I was compelled to leave the city on a professional visit to 
Indiana. I left on Friday afternoon and returned on Monday morning, 
at which time I learned that my patient had died on Sunday morning, 
from hemorrhage at the seat of ligature." 

The following is a resume of similar accidents which have from 
time to time occurred in the practice of other surgeons. 

Desault twice observed, after attempts to reduce old luxations of the 
shoulder, " tumeurs aeriennes." It is quite probable, however, that in 
each case the tumor was caused by the rupture of a bloodvessel. 1 

Pelletan, also, attempting to reduce a luxation of four months' stand- 
ing, thought he produced a tumeur aerienne, but it being opened the 
patient bled to death. 2 

Malgaigne, attempting to reduce a dislocation of sixty-eight days' 
standing, was surprised by a sudden tumefaction in the axilla, and on 
the shoulder, which caused so much alarm as to induce him to discon- 
tinue his efforts. Ice was applied, and the hemorrhage, which he 
thought came from muscular branches, was arrested. 3 Yerduc saw 
the axillary artery ruptured in the same manner, in consequence of 
which the patient died. 4 J. L. Petit met with a similar case. Platner 
mentions a case of rupture of both axillary artery and vein. 0. Bell 
reports an example of rupture of the artery with extensive laceration 
of the muscles, and which demanded immediate amputation. Delpech 
ruptured the artery, and his patient died immediately. 5 Flaubert was 
more fortunate, the effused blood being absorbed after a few days. 
Froriep saw his patient die within one hour and a half after a rupture 
of the axillary vein. John C. Warren, of Boston, tied the subclavian 
artery to arrest the progress of an enormous aneurismal tumor in the 

1 Desault, Journ. de Chir., t. iv. p. 301. 2 Pelletan, Chir. Clin., t. ii. p. 951. 

3 Malgaigne, op. cit., p. 150. 

4 Verduo, Operat. de la Chir.. 1693, t. i. p. 559. 

5 Malgaigne, op. cit., p. 152. 



568 DISLOCATIONS OF THE SHOULDER. 

axilla, caused by the reduction of a recent dislocation. 1 Gibson, of 
Philadelphia, lost two patients in attempting to reduce old luxations 
of the humerus, 2 and he relates another fatal case occurring in the 
practice of David, of Rouen. Leudet, of Rouen, lost a patient in this 
way in 1824. In this latter case, and in both the cases occurring in 
the practice of Gibson, there was a fracture, also, of the lower margin 
of the glenoid cavity. 

In addition to these lesions of arteries and veins caused by attempts 
at reduction of dislocated shoulders, in both recent and ancient cases, 
there are several examples recorded of sudden death when no such 
lesions were disclosed in the autopsy. In the case reported by Lis- 
franc death was ascribed to cerebral congestion. MM. Lenoir and 
Larrey refer to cases, also, of lesions of the brachial plexus, causing 
paralysis, yet these were recent cases, and the reduction was easily 
accomplished. 3 

In the following case an attempt to reduce an ancient dislocation 
of the humerus occasioned a fracture of the surgical neck. 

Martha Hogan, set. 70, of Brooklyn, N. Y., was admitted into the 
Long Island College Hospital during the spring of 1860. The dislo- 
cation had existed six weeks, and was subcoracoid. On the day of 
admission an attempt was made to reduce it, both by Dr. Johnson and 
myself, without an anaesthetic, in which we both failed. I then gave 
her ether, and now discovered that she had a fracture of the second 
and third ribs on the same side. The fractures were ununited. While 
manipulating, pulling the arm gently and rotating, the surgical neck 
of the humerus gave way. She did not survive the injury many 
days, and the autopsy confirmed this diagnosis. 

Norris has reported three cases of ancient dislocation into the 
axilla, treated at the Pennsylvania Hospital; one, of four weeks' 
standing, was reduced in thirty seconds by the aid of the pulleys ; 
the second, which had existed seven weeks, was reduced by the same 
means in about one hour ; and the third, dislocated ten weeks, was 
left unreduced after extension and counter-extension had been made 
for an hour. In the second case, however, suppuration occurred in 
or about the joint, and, on the tenth day, the abscess was opened, 
giving exit to a large amount of pus. He left the hospital with the 
parts about the shoulder still much hardened and stiff. 4 

Dislocation, with Fracture of the Humerus near its Upper End. 

We have thus far omitted to speak of the treatment of dislocations 
of the humerus accompanied with fracture near its upper end. The 
older writers, almost without an exception, agree in declaring the re- 
duction of these dislocations impossible, until the fracture had united. 
And, so late as the year 1828, we have the report of a case treated in 
this manner by a surgeon in Massachusetts. Dr. Warren, of Boston, 

1 Warren, Amer. Journ. Med. Sci., vol. xi. N. S. 1846. 

2 Gibson, Elements of Surg., vol. i. p. 824, 4th ed. 

3 Lisfranc, Lenoir, Larrey, Bui. de la Soc. Chir., t. i. 

4 Is orris, Amer. Journ. Med. Sci., xxxi. p. 24. 



DISLOCATION OF HUMERUS NEAR ITS UPPER END. 569 

himself reduced the dislocation at the end of four weeks, when the 
fracture was found to have united. 1 

But since the introduction of anaesthetics immediate attempts at 
reduction have more often proved successful ; and in no case can the 
surgeon excuse himself for having omitted to make the effort. 

Kichet reports an example of this kind in a man sixty-eight years 
of age, in whom the dislocation was complicated with a fracture of 
the neck of the humerus. The attempt was not made until the fourth 
day, when it proved successful without extension. The fracture was 
afterwards adjusted and consolidated so that he recovered the com- 
plete use of his arm. 2 

At a meeting of the New York Academy of Medicine, in May, 
1855, Dr. Watson reported a case of fracture of the humerus near its 
head, complicated with a dislocation into the axilla. The patient was 
a robust man, past the middle age, and had received the injury by a 
blow on the shoulder from a steam-engine. He was very much pros- 
trated at the time of being admitted into the hospital, and the exami- 
nation was not made until the following morning. The arm was then 
found lying close to the side, but in other respects it presented the 
usual signs of a dislocation. Ether was immediately administered ; 
and while extension and counter-extension were applied, and a sweep- 
ing motion given to the arm, drawing it from the body, firm pressure 
with the fingers was made in the axilla, forcing the head toward the 
socket, and the bone slipped into its position. 3 

In the Transactions of the American Medical Association, I have re- 
ported a case of supposed dislocation accompanied with a fracture, 
which I succeeded in reducing on the eighth day. 4 

During the last two years, however, I have twice failed in attempts 
to reduce similar dislocations. The first patient, John Riley, aet. 49, 
was admitted to Bellevue Hospital, March 29th, 1864, having received 
the injury two days before. The dislocation was subcoracoid, and the 
humerus was broken at its surgical neck. Having placed him under 
the influence of ether, assisted by Dr. Stephen Smith and several other 
surgeons of the hospital, I attempted to reduce the dislocated bone, 
but after a trial prolonged through one hour or more, the effort was 
abandoned. 

The second case was in a man aged about 40 years, who was ad- 
mitted to Bellevue Hospital in July, 1864, with a dislocation of the 
head of the humerus forwards, and a fracture of the surgical neck, of 
four weeks' standing. A surgeon had attempted reduction immedi- 
ately after the receipt of the injury, but had failed. We found the 
fracture still ununited, and placing him under the influence of ether,. 
we tried faithfully, by pushing and pulling and by various other ma- 
noeuvres, to reduce the dislocation, but without success. 

1 Boston Med. and Surg. Journ., No. i., 1828 ; also, Amer. Journ. Med. Sci., vol. ii. 
p. 233. 

2 Richet, Amer. Journ. Med. Sci., vol. xii., new ser., p. 293, from Bulletin de Tlierap- 

3 Watson, Amer. Journ. Med. Sci., vol. xvi., new ser., p. 383. 

4 Op. cit., vol. ix. p. 93. 

37 



570 DISLOCATIONS OF THE SHOULDER. 

The fractures united in both cases promptly, and attempts were 
subsequently made to reduce the dislocation, but to no purpose. 

Other examples have been recorded by surgeons in which the re- 
duction has been accomplished immediately, and without much diffi- 
culty, by simple pressure upon the head of the bone, while the patient 
was under the influence of an anaesthetic, and without the aid of ex- 
tension ; indeed, it is quite doubtful whether extension in these cases 
is of any service. If, however, the surgeon were to fail by pressure 
alone, it would be proper to employ extension and manipulation; 1 in 
the event of a failure by these means, the case ought to be treated as 
a fracture, and the earliest period after the union of the fragments 
should be seized upon to accomplish the reduction of the dislocation. 
The frequent success of the older surgeons by this method is sufficient 
to warrant the attempt. 

The treatment of compound dislocations of this joint will be dis- 
cussed in a separate chapter devoted to the general consideration of 
compound dislocations of all the joints connected with the long bones. 

§ 2. Dislocation of the Humerus Forwards. (Subcoracoid and Sub- 
clavicular.) 

Causes. — The causes of this dislocation are the same with those 
which produce dislocation downwards into the axilla, except that it 
is more likely to occur in a fall upon the elbow or upon the hand 
when the line of the axis of the arm and forearm is thrown behind 
the body. If it is the result of a direct blow, the impulse has usually 
been received rather upon the back than upon the outer side of the 
head of the humerus; or the upper end of the bone having been 
originally thrown directly downwards upon the inferior edge of the 
scapula, may have been made to assume the position forwards, be- 
neath the pectoral muscle, in consequence of the peculiar action of 
the muscles, or of the position of the arm in an attempt to rise. By 
this latter mode of explanation the dislocation forwards is consecu- 
tive only upon a dislocation downwards. 

In several instances which have come under my notice the disloca- 
tion has been due to muscular action alone. In one example the 
dislocation occurred frequently in consequence of epileptic convul- 
sions. This was in the person of a lad, set. 18, of a slender frame and 
feeble muscles. When the dislocation had taken place, he was fre- 
quently able to reduce it himself; sometimes he was obliged to call 
upon a surgeon, and at other times he left it out a day or two, or 
until it became reduced spontaneously. This spontaneous reduction 
generally took place at night, during sleep. At the time he called 
upon me the bone had been out two days, and he could not reduce it. 
I administered chloroform, and then made repeated and prolonged 
efforts at reduction, adopting all the usual modes of manipulation, but 

1 Hartsliorne, Case reduced by Manipulation, Amer. Journ. Med. Sci., Jan. 1855, 
pp. 273-4, from Med. Examiner. 



DISLOCATION OF THE HUMERUS FORWARDS. 



571 



Fig. 233. 



without resorting to mechanical appliances. The father now refused 
to allow me to proceed, and he was taken home with the bone unre- 
duced. The following day he called at my office, to say that during 
the night, while asleep, and, he thinks, while turning over in bed, the 
bone suddenly resumed its place. 

Pathology. — Omitting for the present to speak of partial luxations, 
the existence of which, as a form of traumatic dislocation, we are pre- 
pared to question, we shall proceed at once to describe the anatomical 
relations and the various lesions which generally accompany a com- 
plete luxation forwards. 

Of these we shall observe two principal varieties, differing mainly 
in the degree or extent of the displacement. 

Thus we may find the head of the humerus resting beneath the 
coracoid process, having the conjoined tendon of the short head of the 
biceps and of the coraco-brachialis 
lying upon its anterior surface, while 
its posterior and outer surface rests 
upon the venter of the scapula in 
front of the glenoid fossa ; in which 
position it has usually thrust up, to 
a greater or less extent, the belly of 
the subscapular muscle. 

Sir Astley Cooper, Fergusson, and 
others, when mentioning this form 
of dislocation, call it a "dislocation 
into the axilla;" by Boyer it is called 
a "primary luxation forwards." Dr. 
Wood, of New York, has reported 
an example, accompanied with a 
fracture of the neck of the humerus, 
which he has named "dislocation 
under the subscapular] s muscle." 
The drawing which accompanied 

the report, made from the autopsy, sufficiently shows that it was a 
dislocation of the same character as that which we are now describ- 
ing. 1 Dr. Parker has called attention to a similar case, an account of 
which was first given in Eeese's edition of Cooper's Surgical Dic- 
tionary. The head of the humerus reposed in the "subscapular fossa." 2 
By Malgaigne, Yidal (de Cassis), and others, this is called a subcora- 
coid dislocation, a term which, as being more distinctive and appro- 
priate than either of the others, I shall choose to adopt. 

In the second variety, the head, having escaped from underneath the 
coracoid process, is made to approach nearer to the sternum, so as to 
apply itself more or less closely to the inferior edge of the clavicle. 
In which case the head and neck will be placed behind the pectoral is 
minor, and also behind the short head of the biceps and coraco-bra- 




Subcoracoid dislocation. 



1 Wood, New York Journ. of Med., May, 1850, p. 282. 

2 Parker, New York Journ. of Med., March, 1852, p. 187. 



572 



DISLOCATIONS OF THE SHOULDER. 




Subclavicular dislocation. 



chialis; or between these several muscles on the one hand, and the 

serratus magnus, covering the second and third ribs, on the other hand. 

Upon the appearances which accompany this more advanced form 

of dislocation writers have generally 
Fig. 234. based their descriptions, diagnosis, 

treatment, &c, of forward luxations. 

In either form of the accident, the 
deltoid, with the supra, and infraspina- 
tus, is greatly stretched, and the two 
latter sometimes torn; the subscapu- 
laris is displaced upwards and back- 
wards, while its tendon is in some in- 
stances completely wrenched from the 
head of the humerus. Mr. Erichsen 
has seen the lesser tubercle itself com- 
pletely broken off in two examples of 
this accident which he has been per- 
mitted to examine after death. 1 Occa- 
sionally the axillary nerves are carried 
forwards with the head of the bone; 
and in this case the pain produced by 
their being thus pressed upon is even 
greater than in dislocations into the axilla. 

In this accident, as in dislocation downwards, the long head of the 
biceps is sometimes broken; the circumflex nerve may be contused or 
ruptured, and the capsule is generally torn very extensively. 

Symptoms. — If the dislocation is subclavicular (Fig. 234), a depression 
exists under the outer end of the acromion process, extending also un- 
derneath its posterior margin ; the elbow hangs away from the body, 
and a little backwards ; the axis of the limb is much changed, being 
thrown inwards in the direction of the middle of the clavicle, the 
whole body inclining moderately to the same side ; there is also more 
or less inability to move the arm, especially in a direction forwards or 
outwards ; a fulness is seen underneath the clavicle, and to the sternal 
side of the coracoid process, occasioned by the head of the humerus; 
the head moving with the shaft. To these we may add the common 
"sign of all dislocations of the humerus, mentioned by Dugas, viz., the 
impossibility of placing the hand upon the opposite shoulder while at 
the same moment the elbow is made to touch the front of the chest. 

If the dislocation is forwards, but subcoracoid, the head of the bone 
will be found below this process and deep in the anterior margin of 
the axillary fossa. It cannot, therefore, be so distinctly felt ; but the 
other signs are the same as in the dislocation forwards under the 
clavicle. 

Prognosis. — "While on the one hand experience has shown that the 
axillary nerves and artery are less liable to suffer serious and permanent 
injury than in dislocation downwards, and that the capsule, with the 
tendinous and muscular tissues about the joint, are no more liable to 



1 Erichsen, Science and Art of Surgery, 2d Amer. ed., p. 250. 



DISLOCATION OF THE HUMERUS FORWARDS. 



573 



laceration, on the other hand, the difficulty of reduction has been often 
increased, and consequently a large number of examples, in propor- 
tion to the actual number which occur, have been left unreduced. 

Fig. 235. 




Subcoracoid luxation. 



Dr. Norris relates, a case which the surgeon who was first called 
supposed to be a mere contusion, but which, on being admitted to the 
Pennsylvania Hospital, three months after the accident, was found to 
be a dislocation forwards under the clavicle. The arm was almost 
useless. Dr. Norris made extension and counter-extension with pul- 
leys nearly an hour, but to no purpose ; and finally, at the request of 
the patient, the attempt was given over. 1 

Treatment. — The same rules of treatment which we have established 
in relation to dislocations into the axilla will be found to be applicable 
to this dislocation, with the exception that the extension will have to 
be made, generally at first, somewhat in a line backwards from the 
body, and that our efforts will frequently have to be continued with 
more perseverance, although with less fear of injury, in consequence 
of supposed adhesions between the artery and the adjacent tissues. 
The extension also must always be made downwards and outwards, 
if the dislocation is subclavicular, until the head of the bone has es- 
caped from beneath the coracoid process ; we may then pull directly 
outwards or even upwards, while at the same moment pressure is 
made with the hand upon the head of the bone in the direction of the 
socket. 

1 Norris, Amer. Journ. Med. Sci.; vol. xxv. p. 279. 



574 DISLOCATIONS OF THE SHOULDER. 

If the dislocation is subcoracoid, our modes of procedure need 
scarcely vary in any respect from those which we have recommended 
for dislocations into the axilla. 

The plan adopted in the following case has been found sufficient in 
several examples of subcoracoid dislocation. 

Mr. McA., of Buffalo, set. 73, moderately muscular, fell through a 
trap-door, striking upon his right elbow, and dislocating the humerus 
forwards. Within two hours after the accident, I found the head of 
the bone resting under the coracoid process, where it could be dis- 
tinctly felt and seen. There was a marked depression under the 
acromion process, and the arm was carried out from the body and 
slightly back. He had not suffered much pain. The patient was 
seated in a chair, and while Dr. Lemon, who was at that time my 
pupil, supported the acromion process, I pushed the head of the hu- 
merus outwards toward the socket with my left hand, while with my 
right I pulled gently upon the arm in the direction of the axis of the 
body. After about twenty seconds it slid suddenly into its place 
with an audible snap. 

Simple manipulation alone will also be found sufficient in many 
cases of subclavicular dislocation. 

A German, Simeon Grennas, set. 21, fell upon an icy side-walk, and 
dislocated his right humerus under the clavicle. We found him about 
an hour after the accident sitting with his head inclined to his right 
side, and supporting his elbow with his left hand. A marked depres- 
sion existed under the outer end of the acromion process, and instead 
of the usual fulness there was a flatness under the process behind. 
The elbow was carried out from the body, and very slightly backwards. 
While Dr. Boardman supported the acromion process I lifted the elbow 
from the side, carrying it first upwards and backwards, and then for- 
wards, making thus a short detour with the arm, and when the ma- 
noeuvre was nearly completed the bone slid into its socket with a slight 
snap. ISTo extension was used, and no more force was employed than 
was sufficient to lift and rotate the arm. He was not at the time of 
the reduction faint, nor were his muscles relaxed from any other 
cause. 

More than once I have accomplished the reduction by extension 
made directly upwards, as in the following example. 

A gentleman, forty-five years of age, had his left shoulder dislocated 
forwards under the clavicle in a railroad collision, on the 8th of Octo- 
ber, 1858. A young surgeon had been making extension in various 
ways for half an hour, when, by placing my foot upon the top of the 
scapula and drawing the arm directly upwards, I accomplished the 
reduction immediately and without much effort. Six months after 
the accident, I found the deltoid muscle considerably wasted, and he 
was still unable to raise his arm to a right angle with the body. 

I have in this way also reduced a dislocation which had existed 
seventeen days, the nature of the accident having been misunderstood 
by the attending surgeon. The man was twenty-three years old, and 
quite muscular. The dislocation had been produced by a severe blow 
received directly upon the shoulder, and the arm was still considerably 



DISLOCATION OF THE HUMERUS BACKWARDS. 575 

swollen and very tender. The reduction was accomplished in a few 
seconds while the patient was under the influence of chloroform, but 
by my hands alone, aided only by the pressure of the foot upon the 
top of the scapula. 

In December, 1857, Dr. White, of Buffalo, and myself, reduced a 
subclavicular dislocation of the right shoulder, which had existed sixty 
days, in a man sixty-eight years of age. The surgeon who first saw 
the man thought it was only a sprain or a severe bruise. When he 
came to Buffalo, the whole limb was enormously swollen, and neither 
Dr. White nor myself had much expectation of accomplishing a re- 
duction without a resort to pulleys and anaesthetics. He was, however, 
placed upon the floor, and after extension made for about half an 
hour, during which time we had pulled the arm in various directions, 
upwards, outwards, and downwards, I at last succeeded while my heel 
was placed in the axilla, and while the limb was undergoing a slight 
rotation. ISTo anaesthetic was employed. 

These several cases are mentioned that the surgeon may understand 
how impossible it is always to establish absolute and invariable rules 
of procedure which shall be applicable to every accident of this cha- 
racter. The method which will succeed readily in one case may fail 
completely in another, although belonging to the same class, and not 
apparently differing in its anatomical relations. Before relinquishing 
the attempt, we ought to have put into requisition all the expedients 
which the experience of other surgeons has shown to be worthy of a 
trial. 

Within the last year I have seen two ancient subcoracoid disloca- 
tions at Bellevue Hospital. One of these cases, in the person of James 
Thompson, aet. 49, has existed two years or more. He is employed 
about the hospital as a carpenter, and has a tolerably useful arm. The 
second, in the person of Rosanna Casey, aet. 32, had existed six weeks 
when she was admitted. Various attempts had been made to reduce 
the dislocation before admission. During the week following her 
admission an attempt was made at reduction by Dr. Verona, an in- 
telligent house surgeon, subsequently by Dr. James R. Wood, and at 
the end of three months the attempt was made by myself, before the 
class of medical students, the patient being each time under the influ- 
ence of an anaesthetic. She was finally discharged with the bone still 
unreduced. 

Mary Coffee, aet. 46, was admitted also to the Charity Hospital, in 
Feb. 1864, with the same dislocation, which had existed six months, 
having been mistaken at first for a fracture. I found her arm free 
from swelling or paralysis, and moving quite freely in its new socket, 
and declined to make any attempt at reduction. 

§ 3. Dislocation of the Humerus Backwards. {Subspinous.) 

This form of dislocation has been seldom met with. Only two 
cases, according to Sir Astley Cooper, occurred in Guy's Hospital in 
thirty-eight years; but in the last edition of Sir Astley Cooper's 
treatise on Fractures and Dislocations, edited by Bransby Cooper, nine 



0/0 DISLOCATIONS OF THE SHOULDER. 

cases are mentioned. 1 Sedillot. 2 Malgaigne, Desclaux, 3 Van Buren, 4 
W. Parker, 5 Lepelletier, 6 Towbriclge, 7 Physiek, Snyder, 8 and myself, 
have each seen one example. 9 

Causes. — One of the patients mentioned in Mr. Cooper's book had 
his shoulder dislocated backwards in an epileptic convulsion ; one had 
fallen upon his shoulder; another met with the accident while push- 
ing a person violently with the arm elevated ; and a fourth, seen by 
Coley, was " pulled down by a calf which he was driving, a cord hav- 
ing been tied to one of the calf's legs, and being held fast by the 
man's hand." My own patient, Frederick Kretner, had his arm caught 
in machinery on the 14th of Jan. 1860. The dislocation was dis- 
covered when I was preparing to amputate the arm soon after the 
accident occurred. Of the manner in which the other cases were pro- 
duced no precise acconnt is given. Desclaux's patient fell from a 
height with his arm in front of him. In the case seen by Dr. Parker, 
of New York, a woman, set. 60, had fallen forwards and struck upon 
the outside of her elbow, arm, and shoulder. No attempt was made 
to reduce it until the fourteenth day, she not having for some time 
called the attention of any surgeon to its condition. Trowbridge's 
patient was thrown from a horse, striking on the palm of his hand. 

Pathology. — Mr. Cooper has given us a careful account of the dis- 
section in the case of Mr. Complin, already alluded to, whose arm had 
been dislocated by muscular spasm. This gentleman was fifty-two 
years of age, and had been subject to epileptic fits, in one of which the 
shoulder was dislocated. Many attempts were made to reduce it, but 
although it seemed to be easily drawn into its socket by extension 
merely, yet, as soon as the force ceased, the head of the bone slipped 
again upon the dorsum scapulas, and in this situation it was finally 
permitted to remain until his death, which did not take place until 
five years after. In the mean time he was able to move the limb but 
very slightly, so that his arm was almost useless. 

Mr. Cooper, to whom the arm was sent after death, found the head 
of the bone resting under the spine of the scapula, and against the 
posterior edge of the glenoid fossa, where it had formed a slight de- 
pression, and the head itself had become somewhat changed in form 
by absorption. The tendon of the subscapularis muscle and the 
internal portion of the capsular ligament were torn at the point where 
the muscle was inserted, but the greater portion of the capsule re- 
mained, having been pressed back by the head of the bone. The 
supra-spinatus was stretched, while the infra-spinatus and teres minor 
were relaxed. The long head of the biceps was elongated, but not 

1 A. Cooper, op. cit., p. 352. 

2 Sedillot, Amer. Joura. of Med. Sci., vol. xiii. p. 551, Feb. 1834. 

3 Desclaux, New York Journ. of Med., Nov. 1851, p. 109, from Revue Medicale. 

1 Van Buren, ibid., Nov. 1851, p. 110. 5 Parker, ibid., March, 1852, p. 186. 

6 Lepelletier, Amer. Journ. Med. Sci., vol. xvi. p. 526, from Arch. Gen., Nov. 1*31. 

7 Trowbridge, Bost. Med. and Surg. Journ., vol. xxvii. p. 99. s Gibson's Surgery. 
9 Examples have also been seen by Dupuytren, Arnolt. Best, Levacher, Berard, Fi- 

zeau, Velpeau, Fergusson and Kirkbride. ±\ew York Journ. Med., March, 1852, p. 
193. 



DISLOCATION OF THE HUMERUS BACKWARDS. 



577 




ruptured. The glenoid fossa was rough and irregular upon its sur- 
face, the cartilage being absorbed. 

The fact that the bone would not remain in place when reduced, 
was explained by the rupture of the subscapularis, and the consequent 
loss of antagonism to the action of the infra-spinatus and teres minor. 1 

The accompanying drawing is a copy of that furnished by Mr. 
Cooper, to illustrate the position occupied by the bone. 

I ought to mention that this case has been regarded by Yidal (de 
Cassis), Malgaigne, and others, as only 
subacromial, and as a variety of the dis- Fi S- 236 - 

location backwards, differing from that 
in which the head of the bone occupies 
a position underneath the spine. But 
as I can see no difference except in the 
degree or extent of the displacement, I 
prefer not to regard the distinction made 
by these surgeons. 

Symptoms. — The signs of this accident 
are, a projection under the spine of the 
scapula, produced by the head of the 
bone, the head being obedient to the 
motions of the arm; a corresponding 
depression in front and under the outer 
extremity of the acromion process; a 

wide space between the head of the bone subspinous dislocation. 

and the coracoid process, into which the 

fingers may be pushed deeply; the axis of the shaft of the humerus 
directed upwards and outwards toward a point posterior to the glenoid 
fossa; the forearm carried forwards across the chest; the humerus 
rotated inwards, unless the subscapularis muscle is torn ; immobility, 
but the motions of the arm are not generally so much impaired as in 
either of the other dislocations ; and finally, as in all other dislocations 
of the humerus, the hand cannot be laid upon the opposite shoulder 
while the elbow touches the front or side of the chest. In Parker's 
case the elbow was thrown outwards, although the arm was carried 
very much across the chest. Desclaux's patient held his hand upon 
his head, with his arm horizontally across his body. 

Usually the diagnosis will be easily made; in my own case the 
position of the head of the bone was easily recognized, but Sir Astley 
relates one case in which, on the morning following the accident, a 
surgeon was unable to discover the dislocation, and on the seventeenth 
day Bransby Cooper failed to make the diagnosis ; nor, indeed, on the 
twenty-third day did Sir Astley himself determine that it was a 
dislocation, until he had unexpectedly reduced it while manipulating 
upon the arm. In a second example, Sir Astley at first believed it 
to be a fracture, but a more careful examination showed it to be a dis- 
location backwards. In this instance the limb could not be rotated 
outwards, as the subscapularis was not torn, and continued to offer 



Sir Astley Cooper, op. cit., p. 354. 



578 DISLOCATIONS OF THE SHOULDER.. 

resistance when the arm was moved in this direction ; he was also 
suffering much more pain than did the other patients, owing, as Sir 
Astley thinks, to pressure upon the articular nerves. In the case of 
Mr. Collinson, also mentioned by Mr. Cooper, a surgeon, who saw the 
patient immediately after the accident, failed to discover the true 
nature of the injury ; and Trowbridge's patient had suffered a disloca- 
tion several weeks before the nature of the accident was fully 
determined. 

Prognosis. — The reduction has always been sooner or later accom- 
plished, except in one instance ; in this case we have seen that the arm 
never recovered any considerable degree of usefulness. . Mr. Collinson's 
arm, reduced on the second day, was restored to all of its functions 
within one month. Dr. Parker's patient had nearly recovered the 
complete use of her arm at the end of four weeks, although it was not 
reduced until it had been out fourteen days. Sedillot succeeded in 
reducing the dislocation in the case of his patient, at the end of one 
year and fifteen days. Lepelletier after forty-five days. Trowbridge 
after forty days ; and in this latter case we are informed that the arm 
was restored to usefulness. 

Treatment. — In the first case mentioned by Sir Astley Cooper, "the 
bandages were applied in the same manner as if the head of the hume- 
rus had been in the axilla, and the extension was made in the same 
direction as in that accident" (downwards and a little outwards). In 
less than five minutes the bone slipped into its socket with a loud snap. 
The second case was treated successfully in the same way. Mr. Dunn 
also having failed to reduce by pulling upwards, finally succeeded by 
pulling at the wrist downwards and forwards, while an assistant pushed 
the head of the bone toward the socket ; the heel was not placed in 
the axilla, which Mr. Bransby Cooper thinks would have only retarded 
the reduction. Mr. Key also failed to accomplish reduction while car- 
rying the arm upwards and backwards, but when the patient had be- 
come faint, by placing the heel in the axilla and pulling downwards a 
minute or two, the bone was reduced. Yidal (de Cassis) recommends 
the same plan, namely, that we shall pull in the direction in which we 
find the limb ; Trowbridge employed the pulleys successfully, the ex- 
tension being made downwards and forwards ; while Dr. Parker suc- 
ceeded equally well with his patient, by " pulling the arm outwards, 
downwards, and slightly forwards." Counter-extension was at the 
same time made by a sheet in the axilla, and the head of the humerus 
was pushed toward the socket by the hand. In Mr. Collinson's case, 
the scapula was supported by a towel, while " gradual extension of the 
limb was made directly outwards, and then the arm being moved 
slowly forwards, the head of the bone was distinctly heard to snap into 
its socket." The time occupied was not more than two or three 
minutes. Sir Astley, however, seems to give the preference to the 
method which succeeded so happily in the case of Mr. G., while he was 
still manipulating with a view to determine the character of the ac- 
cident. " I readily reduced the bone," he remarks, " by raising the 
hand and arm, and by turning the hand backwards behind the head." 
In one other instance, having failed to reduce it by slight extension 



PARTIAL DISLOCATIONS OF THE HUMERUS. 579 

outwards, he raised the arm perpendicularly, at the same time forced 
it backwards behind the patient's head, and the reduction was promptly 
effected. In the case of Kretner, I first attempted reduction by pres- 
sure directly upon the head of the humerus, but failing, I proceeded 
to pull the arm with moderate force outwards and downwards, which 
procedure was attended with immediate success. The patient was 
under the influence of chloroform. 

After the reduction, a compress should be placed against the head 
of the bone, and underneath the spine of the scapula, and this should 
be secured in its place by several turns of a roller. The forearm 
ought also to be placed in a sling, with the elbow thrown a little back 
of the centre of the body, so as to direct the head of the humerus 
forwards. 



§ 4. Partial Dislocations or the Humerus. 

Sir Astley Cooper has related in his treatise two cases of supposed 
incomplete luxation of the head of the humerus forwards ; and in con- 
firmation of his views he has added an account of the appearances 
presented on dissection in the body of a subject brought into the 
rooms of St. Thomas's Hospital. Bransby Cooper, in his edition of 
the same work, furnishes the report of a similar case which came 
under the observation of Mr. Douglass, of Glasgow. Hargrave and 
Dupuytren have each reported one example of this species of dislo- 
cation, in which its existence was said to be confirmed by dissection. 

Petit, Duverney, Chopart, Sedillot, Miller, Gibson, Malgaigne, and 
many others, have admitted its possibility ; Malgaigne, however, only 
admits its existence when the capsule remains entire. 

Without intending to discuss very much at length the value of 
these opinions, I shall content myself with declaring that the exist- 
ence of this, or of any other form of partial luxation of the shoulder- 
joint, as a traumatic accident, has not up to this moment been fairly 
established ; and that the anatomical structure of the joint renders its 
occurrence exceedingly improbable, if not absolutely impossible. 

The only example mentioned by Sir Astley Cooper, in which a 
dissection was made, showed that the long head of the biceps had 
been ruptured, and that the capsule was torn, while the head of the 
humerus was resting under the coracoid process. We shall have no 
difficulty, therefore, in assigning it to its proper place as a complete, 
subcoracoid dislocation. In Mr. Hargrave's case, also, the tendon of 
the biceps was torn ; while Dupuytren omits to mention what was the 
actual fact in relation to this tendon in the case seen by him, but it is 
distinctly stated that the head of the bone rested upon the ribs. Mr. 
Hargrave seems, therefore, to have described a case of rupture of the 
long head of the biceps, and it is probable that Dupuytren, who knew 
nothing of the previous history of the subject, has given us a faithful 
account of a pathological dislocation, a result of disease, and not of a 
direct injury. 

If the head of the humerus is driven from its socket by violence, 
and remains thus displaced, it is, we assume, a complete luxation ; 



580 



DISLOCATIONS OF THE SHOULDER. 



Fig. 237. 



since it is only by having placed the semi-diameter of the head of the 
bone outside of the margin of the glenoid fossa that it can be made 
for one moment to retain its abnormal position. To accomplish this 
amount of displacement upwards, or upwards and forwards, or directly 
forwards, the acromion or the coracoid process must be broken ; 
while its occurrence in any other direction must involve at least a 
most extraordinary extension, if not an actual laceration, of the cap- 
sule. If we admit, with Malgaigne, that occasionally the capsule has 
been found capable of such extraordinary extension without actual 
rupture, we still are unwilling to regard this as a fair example of a 
partial dislocation, since the head of the bone no longer moves in its 
socket, being at no point in actual contact with the articular surface 
of the glenoid fossa. It is essentially a complete dislocation, accord- 
ing to all the admitted definitions of this term. 

It is quite probable that a majority of these accidents were examples 
of rupture or of displacement of the tendon of the long head of the 

biceps, the effect of which, as Mr. 
John G-. Smith 1 and Mr. Soden 2 have 
shown by a number of dissections, 
is to allow the head of the humerus 
to be drawn upwards and forwards 
in its socket, until it is arrested by 
the two processes, and by the co- 
raco-acromial ligament. Says Mr. 
Soden : " To enable the bone to main- 
tain its equilibrium, it is necessary 
that the capsular muscles should 
exactly counterbalance each other; 
and as there is no muscle from the 
ribs to the humerus to antagonize 
the upper capsular muscles'.' (that is, 
to draw the head of the humerus 
downwards), "it is suggested that 
this office is performed by the sin- 
gular course of the long tendon of the biceps, which, by passing over 
the head of the bone, when the muscle is put in action, tends to throw 
the head downwards and backwards ; it follows, therefore, that, the 
tendon being removed, the head of the bone would rise upwards and 
forwards." 

The drawing (Fig. 237) represents the case of displacement of the 
tendon of the biceps seen by Mr. Soden, and of which he had been 
permitted to make a dissection. 3 

I have myself frequently observed, and I have before, when speaking 
of the prognosis or results of dislocations, called attention to the fact, 
that the head of the humerus sometimes remains for a long time after 
the reduction has been effected slightly advanced in its socket, so as 




Displacement of the long head of the biceps. 



1 Amer. Journ. Med. Sci., vol. xvi. p. 219, May, 1835, from Lond. Med. Gaz. 

2 Ibid., vol. xxix. p. 480, from Lond. Med. Gaz., July, 1841. 

3 Pirrie's System of Surg., Amer. ed , p. 255 ; also, Sir Astley Cooper, edited by 
Bransby Cooper, Amer. ed., p. 363. 



PARTIAL DISLOCATIONS OF THE HUMERUS. 581 

to lead to a suspicion that it is not properly reduced. Quite recently 
I Lave been consulted in the case of a lad about fourteen years of age, 
who had been subjected to the pulleys during four consecutive hours 
to accomplish a more complete reduction. 

The same thing, also, has been noticed by me occasionally where 
the shoulder had been subjected to a violent wrench, but no actual 
dislocation had ever occurred. In either case the explanation is 
perhaps the same, the long head of the biceps has been broken or 
displaced; or, when it follows a dislocation, some of the muscles 
inserted into the greater tuberosity have been torn from their attach- 
ments. I mean to say that in these circumstances we may find a 
sufficient and perhaps the most frequent explanation ; yet it is quite 
probable that in a considerable number of cases, the laceration of the 
capsule, and the action of the muscles, are alone concerned in the 
production of this phenomenon. I have seen one example in the 
person of Mr. Craig, of Brooklyn, in which the tendon of the biceps 
suddenly resumed its position after the lapse of several days, and the 
prominence of the head of the humerus at once disappeared. 

Alfred Mercer, of Syracuse, N. Y., in a very interesting paper on 
this same subject, relates several examples of forward displacement 
after injuries to the shoulder-joint, one of which, as being exceedingly 
pertinent, I shall take the liberty of quoting. 

"Mrs. B., a well-developed woman, of full habit, aged fifty-six, seven 
years since was thrown from a carriage, dislocating her right shoulder, 
which was reduced a short time after the accident, but the shoulder 
was painful, and tender to the touch, and almost useless for months 
after. She could carry the arm forwards and backwards, but could 
not raise it from the side, or carry the hand behind her, or raise it to 
her head, for fourteen months. She has gradually gained better use 
of her arm, but now, July, 1858, she cannot raise the elbow from the 
side more than half-way to a horizontal position without assistance ; 
but with assistance, the arm may be carried into any position without 
pain or resistance. Measurement shows no appreciable difference in 
the size or length of the arm, or size of the shoulder ; but the point of 
the shoulder is still tender to the touch, is prominent in front, and 
correspondingly flattened behind. The head of the humerus appears 
to rest against the outside of the coracoid process, but the fulness of 
habit obscures the diagnosis, compared with the other cases. Several 
doctors, at different times, have examined the shoulder ; some have 
said it was not properly reduced, and advised a suit for malpractice. 

" I examined the shoulder again in November last ; it presented the 
same general appearance, although the patient was much thinner in 
flesh from recent sickness. Some six weeks previous to this exami- 
nation, in a sudden and thoughtless effort to raise the arm above the 
head, the muscles unexpectedly obeyed the will ; since which time 
she has had perfect use of it, though the deformity still remains. She 
thinks she felt or heard a snap when the arm went up, but it was 
followed by no pain, soreness, or swelling." 1 

1 Mercer, Buffalo Med. Journ., vol. xiv. p. 641, April, 1859. 



582 DISLOCATIONS OF THE HEAD OF THE EADIUS. 

There can be no doubt, we think, that in this case, at least, the 
deformity and maiming were due in a great measure to a displace- 
ment of the long head of the biceps. 1 



CHAPTEE VII. 

DISLOCATIONS OF THE HEAD OF THE RADIUS. 

I have met with twenty-one examples of traumatic dislocation of 
the head of the radius ; of which seventeen were dislocated forwards, 
or forwards and outwards, and only four backwards: or, rejecting 
those cases which were complicated with fracture, I have recorded 
eight cases of simple forward luxation, and two of simple backward 
luxation. My experience, therefore, does not correspond with the 
experience of Boyer, Yelpeau, Yidal (de Cassis), Chelius, B. Cooper, 
Guthrie, Gibson, and some others, who declare that the dislocation 
backwards is the more frequent of the two. Indeed, I ought to say 
of both of the examples of backward luxation of the radius which 
have come under my notice, and which I have marked as simple, that 
they were ancient luxations, and I am not entirely certain, therefore, 
that they had not been originally complicated with a fracture, although 
at the time of my examination they presented no such evidence. I 
have seen one congenital dislocation of the head of the radius outward 
and forward, which I will describe more particularly in the chapter 
on congenital dislocations. 

§ 1. Dislocations of the Head of the Radius Forwards. 

Causes, — A fall upon the elbow, the blow being received directly 
upon the posterior face of the head of the radius ; a fall upon the 
hand with the forearm extended and pronated ; extreme pronation of 
the forearm; or, according to Denuce, a blow upon the inside of the 
elbow, which is equivalent to a violent adduction of the forearm. 

In children, and especially in those of a strumous habit, whose 
ligaments are feeble, a subluxation forwards, or even a complete luxa- 
tion, is occasionally produced by being lifted suddenly from the floor 
by the hand, or by an attempt to sustain the child when he is about 
to fall. I have seen several examples of this latter form of the acci- 
dent produced in this way. Batchelder, 2 Sylvester, 3 Goyrand, 4 and 
many other surgeons, have mentioned similar cases. 

Dr. Krackowizer related to the New York Academy, in 1856, a 

1 Broomfield's Chirurg. Observ., vol. ii. p. 76. 

2 New York Journ. Med., May, 1856, p. 333. 

3 Amer. Journ. Med. Sci., vol. xxxi. p. 206, Jan. 1843. 
* Ibid., vol. xxxii. p. 228, July, 1843. 



DISLOCATION OF HEAD OF RADIUS FORWARDS. 583 



case of complete dislocation forwards, produced, as was supposed, in 
the act of turning the child in delivery. The arm was ecchymosed, 
and the dislocation was very distinct. 1 

Pathological Anatomy. — The head of the radius is carried forwards 
upon the humerus, and generally a little outwards ; the anterior and 
external lateral ligaments, with the 

annular, are in most cases more or Fig. 238. 

less broken. Sometimes the ante- 
rior and external lateral are alone 
broken, the annular ligament being 
then sufficiently stretched to allow 
of the complete dislocation; or the 
anterior and annular having given 
way, the external lateral may re- 
main intact. 

Symptoms. — The head of the 
radius can in general be distinctly 
felt in its new situation, rotating 
under the finger when the hand is 
pronated and supinated; we may 
sometimes also recognize a depres- 
sion corresponding to its natural 
situation, behind and below the 
little head of the humerus. The 
external border of the forearm is 
slightly shortened, and the arm in- 
clines unnaturally outwards. The 
tendon of the biceps is relaxed. 
The forearm is generally pronated, 
sometimes it is in a position mid- 
way between supination and pronation, but I have never seen it 
supinated. I have particularly noticed this fact in my report made 
to the New York State Medical Society in 1855 ; and Denuce, who has 
also examined these cases carefully, affirms that it is seldom supinated, 
notwithstanding the general statements of surgeons to the contrary. 

The arm is usually a little flexed, and cannot be perfectly extended 
without causing pain ; nor can it be flexed much, if at all, beyond a 
right angle, owing to the impediment offered by the humerus, against 
which the head of the radius now impinges. 

Prognosis. — Denuce says : " The reduction is often impossible ; more 
frequently still, difficult to maintain." In proof of which he refers to 
the observations of Danyau and Eobert. In the case of recent luxa- 
tion related by Eobert, it was found impossible to maintain a reduc- 
tion which he thought he had several times accomplished, and he 
believed that the difficulty consisted in a portion of the torn annular 
ligament having become entangled between the head of the radius and 
the condyle of the humerus. 2 




Head of radius forwards. Anatomical relations. 



1 Krackowizer, New York Journ. Med., March, 1857, p. 262. 

2 Memoire sur les Luxations du Coude, par Paul Denuce. Paris, 1S54. 



534 DISLOCATIONS OF THE HEAD OF THE RADIUS. 



Fie. 239. 



Sir Astley Cooper was unable to accomplish the reduction in two 
recent cases; and of the six cases which came under his immediate 

observation, only two were ever re- 
duced. In Bransby Cooper's edition 
of Sir Astley 's work, other similar 
examples of non-reduction are re- 
lated. 

Malgaigne says that in a collec- 
tion of twenty-five cases which he 
has made, the accident was unrecog- 
nized or neglected in six, and in- 
effectual efforts at reduction had been 
made in eleven ; so that only eight 
of the whole number were reduced. 
I have myself met with five of 
these simple dislocations which were 
not reduced, two of which, however, 
had not been recosrnized. and no 
attempts at reduction had ever been 
made ; one had been treated by an 
empiric, Sweet, a " natural bone-set- 
ter," but without success ; one had 
been reduced, but it had become 
reluxated, and in the remaining 
J5/l^/ example I was myself unable to 

reduce the dislocation on the seventh 
day. 

The following are brief notes of 
four of these cases : — 

A young man, get. 23, presented 
himself at my office, to whom the 
accident had occurred about one year before. The surgeon who was 
first called did not recognize the dislocation, and no attempt had ever 
been made to replace the bones. The forearm was forcibly pronated 
and could not be supinated, but he could extend it completely, and 
flex it somewhat beyond a right angle. It was strong, and nearly as 
useful as before. 

H. H. B., set. 6 ; dislocation produced by a fall upon the elbow. 
The surgeon who was called did not detect the nature of the injury. 
Eighteen years after, I found the head of the radius lying in front of 
the old socket, having formed a new socket in which it moved freely. 
From the elbow to the hand the arm inclined outwards, or to the 
radial side ; pronation and supination were perfect. He could flex 
the arm to an acute angle, but not so completely as the other. The 
arm was as strong as the other, but it was frequently hurt by lifting. 
Ira E. Irish, set. 12. " Sweet" was at first employed, but failed to 
reduce it. Thirty-nine years after, when Mr. Irish was fifty-one years 
old, I examined the arm. He could not flex the forearm upon the 
arm beyond a right angle ; and when the attempt was made, the radius 
struck against the humerus. Complete supination was impossible. 




Head of radius forwards 
an.ce of limb. 



External appear- 



DISLOCATION OF HEAD OF RADIUS FORWARDS. 585 

The arm was as strong as the other, except in raising a weight above 
his head. Occasionally he was annoyed with slight pains in this limb. 

Urias Lett, a colored barber of Buffalo, aged forty-eight years, was 
thrown from a carriage, producing dislocation of the right radius, and 
severely bruising the elbow-joint. He drove a couple of spirited 
horses several miles after the accident, and did not see Dr. K., a highly 
accomplished young surgeon, uotil six hours had elapsed. The elbow 
was then much swollen, and exquisitely tender, and Lett would not 
permit much if any examination, to enable Dr. K. to determine his 
condition. The Dr. applied simple dressings, and the next day re- 
quested me to see him. The whole arm was then swollen and tender, 
and very little examination was admissible. The dressings were, 
therefore, not completely removed, but only laid open sufficiently to 
enable us to see the joint. We suspected a forward luxation of the 
head of the radius, but could not positively determine the point — the 
patient not permitting any kind or degree of manipulation. We 
decided, therefore, to wait a few days, until the inflammation had 
somewhat abated, and then, if the existence of a dislocation was ascer- 
tained, to attempt its reduction. On the seventh day the swelling had 
measurably subsided, and the diagnosis became satisfactory. We 
immediately placed him under the complete influence of chloroform, 
and made long-continued and violent efforts at reduction, but without 
success. Severe inflammation again followed these efforts, and Lett 
would never consent to another trial. After four years, I find the 
bone still out. He can flex the forearm upon the arm almost as far 
as he can the opposite limb ; he can carry it nearly to his mouth ; the 
head of the radius sliding off' upon the outer face of the humerus, and 
not resting plumply against it ; indeed, the radius seems to have been 
gradually pushed outwards as well as forwards. The hand is forcibly 
pronated, and cannot be supinated. The attempt to supine produces 
a click in the neighborhood of the head of the radius, as if it struck 
against a bone. The arm is as strong as the other, and not wasted. 
He has constantly pursued his occupation as a barber, after only a few 
weeks' confinement. 

If the dislocation is accompanied with a fracture of the ulna, unless 
the fracture is transverse or incomplete, reduction is not generally 
accomplished. When speaking of fractures of the shaft of the ulna, I 
have related several examples illustrative of this remark. Norris 
has made the same observation. 1 I have, however, three times met 
with this accident thus complicated in children, in the treatment of 
which a much better result has been obtained. In the first example, 
a lad aged nine years had broken the ulna in its upper third and dis- 
located the radius forwards. Dr. White, of Buffalo, and myself were 
in immediate attendance. Both the fracture and dislocation were 
easily reduced, and in a few weeks the limb was sound and perfect, 
except that a slight fulness remained in front of the head of the radius, 
and this continued for several years. In the second example, a lad of 
the same age as the other, was treated by Dr. Austin Flint and my- 

1 Norris, Amer. Journ. Med. Sci., vol. xxxi. p. 21. 

38 



586 DISLOCATIONS OF THE HEAD OF THE KADIUS. 

self. We reduced both the fracture and the dislocation by extending 
the arm from the wrist, while at the same moment pressure was made 
upon the head of the radius from before backwards. A right-angled 
splint was applied and continued during a period of four weeks, being 
removed daily for the purpose of giving to the joint gentle, passive 
motion, &o. After this the arm was permitted to straighten gradually, 
and at the end of a month more the joint was moving freely, and with 
no degree of displacement at the point of fracture or dislocation. 

It is quite probable that in each of the above cases the separation 
was not complete, although crepitus was distinct, and the displacement 
of the broken ends was very marked. In the following case the frac- 
ture was certainly incomplete : — 

Elizabeth Carmody, get. 4, was brought to me, August 6, 1851, with 
a fracture of the ulna, two inches below its upper end, the fragments 
being inclined backwards, while the radius was dislocated forwards. 
Both bones were easily replaced, and the functions of the arm were 
soon completely restored. 1 

Where the restoration has been promptly effected and maintained 
steadily, the motions of the joint are soon restored; but in one case 
the head of the radius has been found to play very freely and loosely 
after the lapse of two years, and in others it has remained slightly 
prominent in front, as if it was a little in advance of its socket. 

Treatment. — Extension and counter-extension should be made in the 
direction in which we already find the limb, namely, with the forearm 
slightly bent upon the arm, while at the same moment the surgeon 
should seize the elbow with his hands, and press the head of the radius 
back with his two thumbs. 

Other methods will often succeed ; but by this we relax the biceps, 
and put the parts in the best position to accomplish the reduction 
easily and promptly. Sir Astley directed to supine the forearm while 
the extension was being made from the hand, but Denuce prefers that 
the forearm should be in a position of pronation. 

After the reduction is effected it is never safe to straighten the arm 
completely at once, nor indeed for some weeks ; not until the ligaments 
have been sufficiently restored to resist the action of the biceps. The 
arm must therefore be flexed and placed in a sling, or, if the radius is 
disposed to become reluxated, a right-angled splint ought to be placed 
upon the back of the arm and forearm, and, by the aid of a compress 
and roller, an attempt should be made to retain it in place. 

Nor will it be found safe at any period to compel the arm by force 
to resume the straight position, since this bone, when it has once been 
dislocated, will for a long time be liable to luxation. 

A boy, aged about four years, was presented at my clinic by his 
father, having a forward dislocation of the head of the radius. The 
dislocation still existed after several months. The father's purpose in 
bringing the child was to ascertain whether he could not claim damages 
for malpractice. The account which he gave was as follows: The 

1 This case was erroneously reported to the N. Y. State Medical Society as an 
example of fracture of the radius, with dislocation. 



DISLOCATION OF HEAD OF EADIUS BACKWARDS. 587 

surgeon called it a dislocation forwards, and pretended to reduce it. 
A right-angled splint was applied with a roller. At the end of three 
weeks the father removed the splint, but did not discover anythiDg out 
of place. Finding, however, that the elbow was stiff, he took measures 
to straighten it forcibly. In a few days he discovered the head of the 
bone out of place, and so it has remained ever since. 

I explained to him that there was much reason to suppose that the 
surgeon had properly reduced the dislocation, and that he had himself 
reproduced the accident, by straightening the arm, through the action 
of the biceps upon the upper end of the radius. The father declined 
any further surgical interference, and no prosecution has followed. 

Dr. Batchelder, of this city, in a very excellent paper on dislocations 
of the head of the radius, describes a method of reduction suggested 
to him first by Dr. Goodhue, of Chester, Yermont, and which he has 
himself found more successful than any other method ; indeed, he says 
it never fails, yet he does not inform us in precisely how many cases 
he has made the trial. The plan suggested by Dr. Goodhue consists 
essentially in first making extension from the hand, and pressing at 
the same time downwards and backwards upon the head of the radius 
until it has descended to a level with the articulating surface of the 
humerus. As soon as this is accomplished, the forearm is to be sud- 
denly flexed upon the arm in such a direction as that the hand shall 
pass outside of the shoulder ; at the same moment, also, the pressure 
must be continued vigorously upon the head of the radius. 1 

§ 2. Dislocation of the Head of the Radius Backwards. 

Denuce has collected fourteen examples of this luxation ; but Mal- 
gaigne, who rejects a portion of these cases, and adds one or two more, 
admits only twelve. In addition to those mentioned by these two 
writers, I have found recorded, or incidentally noticed, one by May, 3 
one by Bransby Cooper, 3 one by Lawrence, 4 one by Liston, 5 two by 
Case, 6 two by Gibson, 7 one by Parker, 8 three by Markoe, 9 and to these 
my own observations have added four more, in all twenty-eight sup- 
posed examples. 

Of the examples brought under my own notice I have already in 
the preceding section affirmed that two of them were accompanied 
with fracture, and I am not entirely certain but that they all were. 
Markoe, of New York, whom we have mentioned as having reported 
three cases, found in each case a fracture of the internal condyle of 
the humerus, and, after an examination of a number of the reported 

1 Goodhue, New York Journ. of Med., May, 1856, p. 333. 

2 May, Sir Astley Cooper on Dislocations, &c, by B. Cooper, op. cit., p. 403. 

3 B. Cooper, ibid., p. 404. 

* Lawrence, Pirrie's System of Surgery, p. 259. 5 Liston, Practical Surgery, p. 88." 

6 Case, Amer. Journ. of Med. Sci., vol. vi. p. 254, from 11th No. of Provincial Med. 
Gazette. 

7 Gibson, Institutes and Practice of Surgery, 6th ed., vol. i. p. 379. 

8 Parker, New York Journ. of Med., March, 1852, p. 188. 

9 Markoe, ibid., May, 1855, p. 382. 



588 DISLOCATIONS OF THE HEAD OF THE RADIUS. 

examples, he does not find any evidence that this dislocation ever 
occurs as a simple uncomplicated accident. I am unable to complete 
the critical analysis which Dr. Markoe has undertaken; yet I confess 
that, so far as I have been able to do so, the testimony strongly con- 
firms his conclusion. While I am prepared to admit the possibility 
of the luxation without either a fracture of the lower end of the 
humerus or of the ulna, I have found no written account of any case, 
nor have I seen an example, which was absolutely conclusive. 

The example reported by Parker as having occurred in the practice 
of N. K. Freeman, of this city, is one of the few which seems to 
admit of but very little doubt. 

In July, 1850, Dr. Freeman was called to see a gentleman, aet. 37, 
who was seriously injured by jumping from the railroad cars while 
they were in motion, and found a backward luxation of the head of 
the radius of the right arm. "The symptoms," says Dr. Freeman, 
" were marked ; the hand and forearm were prone, and the attempt to 
place them in the supine position caused great pain; while the head of 
the radius formed a considerable projection posterior to the external 
condyle of the humerus, where the cavity on its extremity could be dis- 
tinctly felt. Assisted by Dr. Walsh, of Fordham, who firmly grasped 
the humerus, I was enabled- to reduce it by extending the forearm and 
flexing it upon the arm, at the same time pronating the hand, and 
pressing forwards the head of the radius with my thumb. After the 
reduction was effected, I requested Dr. Walsh to examine it ; when, 
upon slight extension being made upon the forearm, with supination 
of the hand, the bone was again dislocated. I immediately reduced 
it in the same manner as before, and directed the patient to keep the 
forearm flexed and the hand prone, and, laying it upon a pillow, apply 
cold water. He complained of severe pain for two days, which gradu- 
ally subsided, and on the fourth day he was able to move and extend 
the forearm." 

Causes. — A direct blow upon the front and upper part of the radius ; 
a fall upon the elbow, or upon the hand ; a violent effort to supinate the 
forearm while it is grasped and held firmly in a state of pronation ; 
probably, also, sometimes it is occasioned by a twisting of the arm in 
machinery, &c. 

Pathological Anatomy. — In the only example of which a dissection 
has been made, reported by Sir Astley Cooper, "the coronary liga- 
ment was found to be torn through at its forepart, and the oblique 
had given way. The capsular ligament was partially torn, and the 
head would have receded much more, had it not been supported by 
the fascia which extends over the muscles of the forearm." The head 
of the radius was thrown behind the external condyle of the humerus, 
and rather to the outer side. This was an ancient luxation found in 
the dissecting-room of St. Thomas's Hospital, and the accompanying 
drawing is copied from the sketch made at the time. 

If the luxation is not complete, as occasionally happens with chil- 
dren, the annular ligament may not be torn. 

Symptoms. — The head of the bone is felt rotating behind the outer 
condyle, and a depression exists corresponding to its original position. 



DISLOCATION OF HEAD OF RADIUS OUTWARDS. 589 



240. 



The forearm is slightly flexed and prone ; and the whole arm is de- 
flected outwards from the elbow downwards ; flexion and extension 
are difficult, while supination is impossible. 

Treatment. — Most surgeons have agreed that while extension and 
counter-extension are being made, the forearm should be forcibly 
supinated. At the same time, also, the head of the 
radius must be strongly pushed forwards. Martin 
recommends to extend forcibly, and then suddenly 
flex the arm, in a manner very similar to the plan 
recommended by Batchelder in dislocations forwards. 
In Dr. Freeman's case, just quoted, the reduction was 
effected while the forearm was pronated, and supina- 
tion seemed to throw it again out of place. 

According to Markoe, where the accident is com- 
plicated with a fracture of the inner condyle, when 
the reduction is accomplished the arm should be 
placed in a position about ten degrees less than a 
right angle, and supported by a splint with band- 
ages, &c. 

If the dislocation is simple, however, I can see no 
objections to its being nearly or quite extended, since 
in this dislocation the action of the biceps would only 
tend to retain the head of the radius in place. 




§ 3. Dislocation of the Head of the E,adius Outwards. 



Dislocation of the 
head of the radius 
backwards. 



Denuce has collected four examples of this accident, 
unaccompanied with a fracture, and he proceeds to 
speak of it as a distinct form of dislocation. In two of the examples, 
however, mentioned by him, it was consecutive upon a forward luxa- 
tion, and I have several times seen the head of the radius very much 
inclined outwards in what are properly termed forward dislocations. 
For these reasons it is not very plain to me that we ought to consider 
this as a distinct form of primary dislocation, but rather as a consecu- 
tive luxation, or at least as only a modification of the forward or 
backward luxation. Indeed, I think the radius never will be found 
thrown directly outwards, but always in a direction inclining forwards 
or backwards. 

Parker, of this city, mentions a case which came under his notice, 
in a child four years old, who, six weeks before, had fallen down stairs 
" backwardly, with the right arm twisted behind the back, in such a 
position that the whole weight of her body came upon her arm." No 
attempt was ever made to reduce the bone, and the head of the radius 
continued to project externally. By pressure it was easily reduced, 
but became immediately displaced when the forearm was either flexed 
or extended. The motions of the joint were completely restored. Dr. 
Parker recommended no treatment. 1 



Parker, New York Journ. Med., March, 1852, p. 1S9. 



590 DISLOCATIONS OF UPPER END OF ULNA BACKWARDS, 



CHAPTEE VIII. 

DISLOCATIONS OF THE UPPER END OF THE ULNA 

BACKWARDS. 

This accident, the existence of which, as a simple luxation, is ren- 
dered probable by a certain number of cases, has nevertheless been 
described so variously, and often indefinitely, that it is impossible to 
declare its history, except in a few points, with any degree of accu- 
racy. No doubt many of the cases which have been reported were 
examples only of a subluxation of both radius and ulna backwards. 
In other cases, the radius or the external condyle of the humerus 
being broken, the ulna has been actually displaced, not only back- 
wards, but upwards; indeed, it is very certain that without either a 
luxation of the radius, or a fracture with displacement of the external 
condyle of the humerus, or a fracture or bending of the radius, an 
upward displacement of the ulna, to the degree represented by the re- 
porters of these cases, could never have occurred. The example 
mentioned by Sir Astley Cooper, and of which a dissection was made, 
is plainly a case of subluxation of both bones ; or if the luxation of 
the ulna may be regarded as having been complete, the head of the 
radius was also displaced more or less upwards from its original 
socket, a new socket, Sir Astley himself informs us, having been 
formed for its reception, upon the external condyle. But this is the 
only example, the actual condition of which has been proven by an 
autopsy. 

Nevertheless it seems possible that a simple luxation or subluxa- 
tion of the ulna backwards may occur without either of the above 

Fig. 241. 




Dislocation of the upper end of the ulna backwards. 



mentioned complications, and that, to the extent of a few lines, it may 
be made to pass upwards upon the back of the humerus, by the 
falling of the forearm to the ulnar side ; in which case the character 
of the accident would probably be recognized by the projection of 
the olecranon process, while the head of the radius might be felt 



DISLOCATIONS OF THE RADIUS AND ULNA. 591 

moving in its socket — by the partial flexion and complete pronation 
of the forearm, and by the general immobility of the joint. 

Its reduction ought to be accomplished easily by the same measures 
which have been found successful in reducing a dislocation of both 
bones backwards. 

Pirrie says that in a case occurring in the practice of Mr. Gosset, 
in which the coronoid process rested on the internal condyle, and the 
pain on bending the arm was insupportable, owing, it was supposed, 
to the pressure of the coronoid process against the ulnar nerve, "re- 
duction was accomplished by extension and counter-extension applied 
by two persons pulling in opposite directions, and by the pressure of 
the olecranon process downwards and outwards, while the forearm 
was suddenly flexed." 1 



CHAPTEE IX. 

DISLOCATIONS OF THE RADIUS AND ULNA (FORE- 
ARM AT THE ELBOW-JOINT). 

The radius and ulna may be dislocated at the elbow-joint back- 
wards ; laterally, that is, either inwards or outwards ; and forwards. 

§ 1. Dislocations of the Radius and Ulna Backwards. 

Causes. — In forty-four cases observed by me, the average age is 
about eighteen years ; the youngest being four years old, and the 
oldest fifty-three. Twenty of this number occurred in children under 
fourteen years of age. 

Generally the dislocation has been produced by a fall upon the 
palm of the hand, as when in running a person has fallen forwards 
with the forearm extended in front of the body, or he may have fallen 
from a height ; once I have known it produced by a blow received 
upon the back and lower part of the humerus. 

It is said also to be produced, occasionally, by twisting the forearm 
violently, as when the limb has been caught and wrenched about by 
machinery, by a blow upon the front and upper part of the forearm, 
and by forced flexion. 

Pathology. — The radius and ulna are not only carried backwards 
behind the articulating surface of the humerus, but they are also, 
through the action of the triceps, almost always drawn more or less 
upwards, so that often the coronoid process of the ulna rests in the 
olecranon fossa. In some cases it has been known to mount even 
higher, while in others it is arrested short of this point. The radius 

1 Gosset, Pirrie's Surg., Airier, ed., p. 259. 



592 



DISLOCATIONS OF THE RADIUS AND ULNA. 




Dislocation of the radius and ulna 
backwards. 



Fi S- 242 - still retaining its relative position to the 

ulna, lies upon the back of the humerus, or 
rather upon the posterior margin of its ar- 
ticulating surface. 

The anterior and two lateral ligaments 
are generally more or less completely torn 
asunder; but the posterior ligament and the 
annular do not usually suffer disruption. 

The biceps muscle is drawn over the 
lower articulating surface of the humerus, 
but is in a condition of only moderate ten- 
sion, while the brachialis anticus is forcibly 
stretched or even torn. 

The median nerve is also pressed upon 
in front by the humerus, and the ulnar is occa- 
sionally painfully stretched over the project- 
ing extremity of the ulna from behind. 
Symptoms. — Sir Astley Cooper does not mention particularly the 
position of the arm as to flexion or extension, except to say that "the 
flexion of the joint is in a great degree lost ; nor, in his original work, 
published in London in 1823, is there any illustration accompanying 
the text to indicate in what position he had usually seen the limb ; 
but in the later editions, edited by Mr. Bransby Cooper, is found a 
drawing which represents the forearm at a right angle with the arm. 
It is very certain that Sir Astley never sanctioned this error by any- 
thing which he had written or communicated to others. It is very 
certain, I say, because the fact that it seldom, if ever, occupies this 
position, could not have escaped the notice of one whose experience 
was so large, and whose habits of observation were generally so accu- 
rate. The truth is that it is almost constantly found only slightly 
flexed, or forming an angle in front of about 120°. 

This fact is especially noticed in my records twenty- three times, 
and if it had ever been found in any other position, it would certainly 
have been stated. Once, where the dislocation was accompanied with 
a fracture of the outer condyle of the humerus, the arm was at first 
straight, a position in which it is said to be found occasionally with 
children ; and in the case of a patient admitted to Bellevue Hospital, 
on the lith of December, 1864, the dislocation having existed thirty- 
one days, but unaccompanied with a fracture, I found the arm straight, 
and there existed also a preternatural lateral mobility of the elbow- 
joint ; but never, in any instance, have I found it flexed to a right 
angle ; yet I will not deny that such unusual phenomena are possible; 
indeed, it is certain that they have occasionally been presented, but 
they must be regarded as only exceptional, and as by no means diag- 
nostic of this accident. 

Sir Astley Cooper and Miller declare that in this dislocation the 
forearm is usually supinated ; Pirrie says: "The hand is between prona- 
tion and supination, but more inclined to the latter;" Desault thinks it 
is sometimes in supination and sometimes in pronation; Denuce con- 
cludes that it will occupy that position, whatever it may be, in which 



DISLOCATION OF RADIUS AND ULNA BACKWARDS. 593 

the force of the blow has thrown it ; while by most surgical writers 
no allusion is made to the position of the forearm in reference to pro- 
nation or supination. For myself, I can only say that I have found 
the forearm and hand constantly in a position of moderate but positive 
pronation, and I am compelled to regard it, therefore, as one of the 
usual signs of a backward dislocation of these bones. 

The limb can be neither flexed nor extended without force, and 
such motion is almost always accompanied with pain. It is, however, 
possible in most cases to give to the arm a slight lateral motion, such 
as does not belong to it in its natural condition. 

In front, and deep in the fold of the elbow, is felt the lower end of 
the humerus, forming a hard, broad, and somewhat irregular projec- 
tion, over which the integuments and muscles are swollen, and tender 
to pressure. Behind, the head of the radius may be felt, when not 
much tumefaction exists, rotating or moving under the finger when 
the forearm is supinated and pronated ; while the olecranon process 
projects strongly backwards and upwards. If now we flex the arm 
slightly, this projection of the olecranon process will be sensibly in- 
creased ; but if an attempt is made to straighten the arm, it will be 
diminished, the reverse of what we have seen to happen in cases of 
fracture of the lower end of the humerus (at the base of the condyles). 
This circumstance becomes, therefore, an important diagnostic mark 
between these two accidents. 

The relation of the olecranon process, also, to the condyles is changed, 
and the upper end of this process, instead of being a little below the 
internal condyle, as it would be naturally when the arm is slightly 
flexed, is found generally carried upwards toward the shoulder, from 
half an inch to one inch or more above the condyle. 

Measuring from the internal condyle to the styloid process of the 
ulna, the forearm is shortened ; the same result will be obtained also 
by measuring from the acromion process to either of the styloid pro- 
cesses ; while from the acromion process to the condyle, the length 
will be the same in both arms. 

The signs which have now been enumerated will be sufficient to 
enable us to make the diagnosis promptly in the great majority of 
cases, but if considerable swelling has already taken place, the diag- 
nosis may be rendered exceedingly difficult, if not impossible; and in 
such cases we should confine the patient at once to his bed, and pro- 
ceed to reduce the tumefaction by cold water lotions as rapidly as 
possible, examining the limb carefully from day to day in order that 
we may seize the earliest opportunity to ascertain its actual condition 
and apply the proper remedy. 

In relation to the difficulty of diagnosis in certain examples of this 
accident, and under certain circumstances, Mr. Skey, in his Operative 
Surgery, has made some very judicious remarks. 

" Severe injuries of the elbow-joint, whether in the form of fracture, 
dislocation, or a compound of the two, are frequently followed, at a 
short interval, by swelling of a formidable kind, in which it is impos- 
sible, but by the aid of a perfect intimacy with the anatomical struc- 
ture of the joint, to detect the relations of one part with another ; but 



594 DISLOCATIONS OF THE RADIUS AND ULXA. 

even under this difficulty, the two points in question are readily dis- 
tinguishable. In such forms of swelling, the arm, including the length 
of six inches both above and below the joint, may be involved in the 
extravasation, and this swelling may distend the arm to a circumfer- 
ence of one-third beyond its natural size. In such circumstances, in 
which it is impossible to determine with any certainty whether any, 
or what bones are broken, or whether or not dislocated, the difficulty 
of the case should at once be stated to the friends of the patient." 

Prognosis. — If the luxation is recent, reduction is in general easily 
effected, but if considerable time has elapsed, the reduction is often 
accomplished with difficulty. As to the probability of its reluxation, 
I have already spoken when considering the subject of fractures of the 
coronoid process. Unless this process is broken, it is not likely to 
occur except where some violence has again been applied. It has 
happened to me, however, to find these bones unreduced in several 
instances. In some of these examples surgeons recognized the acci- 
dent and supposed that they had accomplished reduction, while in 
others the dislocation was mistaken for a fracture. 

A lad, W. r., twelve years old, residing in Erie County, N. Y., was 
brought to me six weeks after the accident had occurred. The surgeon 
who was first called declared it to be a dislocation, and told the parents 
he had reduced it; but the dislocation was now complete, and the arm 
immovably fixed in its abnormal position. 

On the tenth of May, 1850, J. P., of Canada West, aet. 25, was 
thrown from a load of hay, striking upon his left hand, and producing 
a dislocation backwards of both bones at the elbow-joint. A Canadian 
surgeon, who saw the patient within three hours, recognized the dislo- 
cation, and by pulling the arm straight forwards he supposed he had 
reduced it; the patient also thought he felt the bones slip into place. 
No attempt was made subsequently to flex the arm, and it was imme- 
diately dressed with a straight splint laid along the palmar surface. 
On the sixth day it was found to be unreduced, and the surgeon again 
attempted to reduce it as before, and thought he had succeeded. The 
same splint was reapplied. At about the end of six weeks three 
surgeons, residing in Canada also, placed the patient under the com- 
plete influence of chloroform, and attempted the reduction. They first 
made extension for half an hour in a straight line, then five men 
seized upon the arm and forearm, bending it with great force to a right 
angle. It was now believed that the ulna was reduced, but not the 
radius. Four days after, the attempt was renewed. Three months 
after the accident the young man called upon me, and I found the arm 
nearly straight, with almost complete anchylosis at the elbow-joint. 
Both the radius and ulna were displaced backwards, but not upwards. 
The arm was of the same length with the other, and the relation of 
the condyles to the olecranon was so manifest, that the absence of the 
usual displacement upwards was easily determined. I was unwilling 
to make any further attempts at reduction, not believing that I should 
succeed after so much time had elapsed, and after so many ineffectual 
attempts had been made by clever surgeons. 



DISLOCATION OF KADIUS AND ULNA BACKWAKDS. 595 

In the following examples the dislocation was supposed to have 
been a fracture of the lower end of the humerus. 

A man, residing in Pittsfield, Mass., dislocated his left arm by fall- 
ing from a horse. The surgeon who was called regarded it as a frac- 
ture at the base of the condyles, and treated it accordingly. Ten 
weeks after, the error was discovered and an attempt was made to 
reduce it, but without success. A second attempt was also made, with 
the same result. 

The patient was brought to me eight months after the accident with 
the bones still unreduced. The forearm hung at a very obtuse angle 
with the arm, and there was very slight motion at the elbow-joint. I 
discouraged any further attempts at reduction. 

Mr. W., of Alleghany Co., K Y., set. 43, fell from a load of hay, 
striking upon his left arm, Feb. 16, 1853. Four hours after, he was 
seen by a young but very intelligent surgeon, who thought the hume- 
rus was broken just above the condyles. After eight weeks, the fact 
that it was a dislocation having become apparent, three surgeons, well 
known to me as men of large experience, attempted its reduction, 
aided by pulleys and chloroform. The patient was also bled, and 
nauseated with antimony. The efforts were protracted through many 
hours, and frequently varied. A second attempt made by these same 
gentlemen, a few days after, was equally unsuccessful. 

On the ninth week Mr. W. came to me, and I placed him at once 
in the Buffalo Hospital of the Sisters of Charity, where, assisted by 
my friend, Prof. Moore, of [Rochester, I renewed the attempt at re- 
duction. The patient was placed under the influence of chloroform, 
and during a great portion of the time occupied the pulleys were 
in use. The elbow was pulled upon, twisted, flexed, and extended, 
until there seemed to be neither adhesions, nor ligaments, nor capsule 
to prevent the reduction. We could move the joint in every direction, 
even laterally, as well as forwards and backwards. Still the bones 
would not return to their sockets. Section of the triceps seemed to 
be the only remaining expedient, but the injury already done to the 
joint was so great that we did not deem it prudent to prosecute the 
attempt any further. We had occupied two hours in the various pro- 
cedures. Violent inflammation supervened, but he was able to return 
home in about two weeks. Two years after, I learned that the arm 
still remained unreduced, and nearly anchylosed; the whole limb was 
also much atrophied and very weak. 

John Sharkie, get. 53, fell on the 4th of Aug. 1854. A botanic doctor, 
who saw him on the same day, and a regular physician, who saw him 
on the third day, thought he had broken his arm. About six weeks 
after this he came under the charge of an almshouse doctor, who 
"rebroke" it, supposing it to be a fracture; and two months later he 
" broke" it again; but as the arm was not improved by these operations, 
he finally urged the poor fellow to submit to amputation ; and it was 
in reference to this last proposition that Sharkie consulted me. I found 
the radius and ulna dislocated backwards and upwards one inch ; the 
arm perfectly straight and the elbow anchylosed ; no pronation or supi- 
nation. I did not think it prudent to make any attempt to reduce it, 



596 



DISLOCATIONS OF THE KADIUS AND ULNA. 



Fig. 243. 



but assured him that if let alone it would ultimately be quite useful 
in many ways, and that he should never think of having it cut off. 

The four last cases which have come under my notice, three of 
which were presented in my service at Bellevue Hospital, were all 
examined previously by reputable surgeons and declared to be frac- 
tures. 

In three or four instances, also, the accident has been overlooked 
by the patient himself, or by some empiric, no surgeon having been 
called to see the case until after the lapse of several days or weeks. 

In general, when the reduction has been effected promptly, the 
patients have recovered the complete use of the elbow-joint within a 
few weeks ; but many exceptions have from time to time come under 
my notice. 

A lad eight years old was brought to me, whose arm had been dis- 
located six months before, and the reduction of which had been ac- 
complished easily and promptly by Sir Astley Cooper's method. At 
this time the arm was bent to a right angle, and quite stiff at the elbows- 
joint. Four years later I learned that 
the stiffness still continued in a great 
measure, with only slight improve- 
ment. 

Treatment. — Sir Astley Cooper thus 
describes his own method of reducing 
this dislocation : " The patient is made 
to sit upon a chair, and the surgeon, 
placing his knee on the inner side of 
the elbow-joint, in the bend of the 
arm, takes hold of the patient's wrist, 
and bends the arm. At the same 
time he presses on the radius and 
ulna with his knee, so as to separate 
them from the os humeri, and thus 
the coronoid process is thrown from 
the posterior fossa of the humerus ; 
and whilst this pressure is supported 
by the knee, the arm is to be forcibly 
but slowly bent, and the reduction is 
soon effected." 

The same practice has been recom- 
mended by Erichsen, Gibson, Samuel 
Cooper, and others. The plan recom- 
mended by Dorsey is nearly identical 
with that just described, only that, in- 
stead of the knee, he advises that the surgeon " interlock his fingers 
in front of the arm, just above the elbow, and draw it backwards." 

On the other hand, Liston and Miller recommend, as a better mode 
of procedure, that the patient shall be seated upon a chair, and that 
the arm and forearm shall be pulled directly backwards, so as to relax 
as completely as possible the triceps muscle, while counter-extension 
is made against the scapula. 




Reduction with the knee in the bend of the 
elbow. 



DISLOCATION OF RADIUS AND ULNA BACKWARDS. 597 

Skey says : " Extension of the forearm should be made from the 
hand or wrist in a straight direction downwards, as if for the purpose 
of simply elongating the arm." 

Pirrie prefers that an assistant shall grasp the forearm near its mid- 
dle, instead of the wrist, and pull the arm straight forwards, while at 
the same moment the surgeon seizes upon the olecranon process with 
the fingers of one hand, and, placing the palm of the other against 
the front and upper part of the forearm, pulls forcibly backwards, so 
as to draw out the coronoid process from the olecranon fossa. 

For myself, having generally practised the method recommended 
by Sir Astley, and having usually succeeded in the first attempt and 
with the employment of only moderate force, I confess that my pre- 
dilections are in its favor ; yet I am not entirely certain but that an 
equal experience with either of the other modes recommended might 
have changed these convictions. The truth is, I think, that in recent 
cases very little force is generally requisite to accomplish the reduc- 
tion, and that it is not very material which of these several modes we 
adopt ; but in case of a failure by one mode, we ought immediately 
and without hesitation to resort to another, as the following case of 
failure by flexion will illustrate : — 

A lad, set. 11, fell in a gymnasium from a height of six feet, striking 
probably upon his hand. I saw him within twenty minutes, and 
found the arm in the nsual position. I attempted immediately to re- 
duce it by Sir Astley's method, but after a fair yet unsuccessful trial, 
I extended the forearm upon the arm until it was nearly straight, 
and then, with only moderate force, drew it promptly into place. 

If we still continue to encounter difficulties, the patient ought at 
once to be placed under the influence of an anaesthetic, and, if neces- 
sary, the pulleys should be employed. 

When the reduction is accomplished, which is indicated generally 
by the sudden slipping of the bones and by the restoration of the 
natural form to the elbow-joint, the surgeon, in order to confirm his 
opinion, must flex the forearm upon the arm to a right angle. If the 
bones are in place, and there is not much swelling, this can generally 
be done without causing much, if any, pain ; but if it cannot be done, 
this fact furnishes presumptive evidence that the reduction is not 
effected. In one instance, however, of recent luxation, this rule has 
not held good. A girl, set. 10, fell from a tree upon her hand. I was 
in attendance within half an hour, and found the usual signs charac- 
terizing this accident. Reduction was accomplished readily by pulling 
at the hand moderately, with the forearm flexed, while my left hand 
pressed back the lower part of the humerus. After the reduction it 
was found impossible to flex the arm to a right angle without causing 
severe pain, and it became necessary, after placing it in a sling, to 
allow the hand to drop very low beside the body. A good deal of 
inflammation followed ; but in a few weeks the arm was well, only 
that for a period of two years or more the elbow remained very 
tender. 

On the other hand, an omission to apply this rule has often led the 
surgeon to believe the reduction accomplished when it was not. Very 



598 DISLOCATIONS OF THE RADIUS AND ULNA. 

recently this same thing has happened to myself, and as it is the only 
instance in which I have omitted to adopt this test, and the only one 
also in which I have left a bone unreduced which I believed to have 
been reduced, it will be proper to state the case and its results more 
fully. 

A lad, set. 11, fell from a fence on the 22d of December, 1858, and 
dislocated both bones backwards. I saw him within two hours from 
the occurrence of the accident. The elbow was already considerably 
swollen and quite tender, but the signs of dislocation were very mani- 
fest. Seizing the wrist with one hand, and placing my knee against 
the front and lower part of the humerus, I pulled steadily for some 
time, and with much more force than is usually necessary, until at 
length two distinct and successive snaps were felt, such as one often 
feels when the two bones resume their sockets. Kelinquishing my 
grasp, it was observed by myself and the parents that the deformity 
had disappeared. The reduction seemed to be complete, and so I 
announced. I then requested the lad to permit me to bend the elbow, 
and placed it in a sling, but this he peremptorily refused to do, and ran 
away from me, nor would any arguments or entreaties persuade him 
to allow me again to touch it. I reassured the parents and child, how- 
ever, that all was right, and left the house. During several successive 
days I saw the little patient, but although the arm remained swollen 
and very tender, I did not suspect the cause until the ninth day ; and 
on the tenth day, having placed him under the influence of chloroform, 
the reduction was easily and satisfactorily accomplished. The recovery 
has been slow. At the end of six weeks I found the motions of the 
elbow-joint not completely restored, and the forefinger was partially 
paralyzed ; but from this condition it has gradually recovered, and 
two months later the functions of the arm and hand were completely 
restored. 

The mistake in this instance was the more mortifying because I had 
just seen a case in a lad only a little older, in which another surgeon 
had committed the same error, and after the lapse of twelve or four- 
teen days I had myself made the reduction ; and I was fully awake, 
therefore, to the possibility of the mistake. 

The circumstance of the diminution, and apparent disappearance of 
the deformity, and the sensation of a double click, can only be explained 
by assuming that originally the coronoid process was resting in the 
olecranon fossa, and that by manipulation the bones had been removed 
nearer their sockets, yet not actually reduced. The swelling, also, 
rendered more difficult a diagnosis which, now, nothing but the flexion 
of the forearm could have determined positively. 

If much time has elapsed since the occurrence of the dislocation the 
reduction is accomplished with difficulty, if, indeed, it can be reduced 
at all. There are many cases upon record, however, in which surgeons 
have been successful after the lapse of many weeks, or even months. 
Boyer thought it was not possible to effect the reduction after four or 
six weeks ; but Capelletti, of Trieste, succeeded after seventy days -, 1 

1 Capelletti, Am. Journ. Med., vol. xix., from Annal. Univ. de Med. for Oct. 1835. 



DISLOCATION OF RADIUS AND ULNA BACKWARDS. 599 

Sir Astley Cooper at three months; 1 Malgaigne after three months 
and twenty-one days. 2 Eoux succeeded in a case of a young man 
twenty -two years of age, whose elbow had been dislocated five months. 3 
Blackman, of Cincinnati, informs me that he has reduced a lateral luxa- 
tion after five months. Brainard, of Chicago, reduced a dislocated 
elbow in a boy of nineteen years, after five months and thirteen days. 
In this case the surgeon who had first seen the patient supposed that 
he had reduced the dislocation. 4 Gorre, Grerdy, and Drake succeeded 
in four cases after six months ; 5 and finally, Starch claims to have 
been successful after two years and one month. 6 To which enumera- 
tion Denuce has added seventeen other examples, said to have been 
reduced at various periods, ranging from one month to one hundred 
and fourteen daj's, 7 

I have reduced quite a number of these old luxations, the four last 
of which will be briefly recorded. 

Mrs. E. Broadway, set. 53, was admitted to Bellevue Hospital in 
Oct. 1865. When she came under my notice the dislocation had ex- 
isted ten days. The internal condyle was broken also, and the surgeon 
had supposed this to be the only accident. I reduced it easily, after 
giving her chloroform, by the method recommended by Dorsey. 

A woman, set. 30, was admitted to the same ward in Jan. 1866, with 
a supposed fracture at the base of the condyles. On the eleventh day 
she was brought to my notice. The reduction was effected in the 
same manner, before the class, but not until ether had been employed, 
and much greater force had been applied than was required in the 
previous case. 

Thomas Robertson, set. 35, was admitted Dec. 14th, 1864, with a 
simple dislocation of the radius and ulna backwards, which had 
existed thirty-one days, but which had not been up to this moment 
recognized by his surgeon. I reduced it before the class, by Sir 
Astley's method, the patient being under the influence of ether. Con- 
siderable force was required. 

Each of these patients recovered without any accidents. 

The next case possesses unusual interest. 

J. G\, set. 7, was brought to me in Nov. 1865, with a backward dis- 
location of the right radius and ulna which had existed nine weeks. 
The arm was nearly straight and fixed. Having placed him under 
the influence of ether, assisted by Dr. Gurdon Buck, of this city, I 
proceeded to flex the arm slowly, and after a few seconds, and when 
the elbow was bent about ten or fifteen degrees, the olecranon process 
separated at the line of epiphyseal union. In a few moments the 
reduction was completed, and the arm brought to an acute angle, but 
the olecranon had separated full half an inch. We were quite certain 
that the ulna was perfectly reduced, but the head of the radius did not 



Sir Astley Cooper, On Dislocations and Fractures, Amer. ed., p. 388. 

Malgaigne, Amer. Journ. Med. Sci., vol. xxiii. p. 238, from Revue Med., Dec. 1837. 

Roux, Amer. Journ. Med. Sci., vol. xvi. p. 526, from Archives Gen., Dec. 1834. 

Brainard, Illinois and Indiana Med. Journ., 1847. 

Memoire sur les luxations du coude, par Paul Denuce, Paris, 1854, pp. 86, 87. 

Denuce, op. cit., p. 87. ' Op. cit. 



600 DISLOCATIONS OF THE KADIUS AND ULNA. 

seem to occupy its original position fully. Only moderate inflam- 
mation ensued. Passive motion was soon commenced, and I have since 
been informed that the motion of the joint is steadily increasing. 

Dr. W. F. Westmoreland, of Atlanta, Gra., has recently reported a 
case in which he succeeded readily in reducing a dislocation of the 
elbow backwards of five months' standing, in a woman aged 22 years. 
The reduction was followed by great pain, a good deal of swelling, 
temporary improvement of circulation in the radial artery, complete 
paralysis of the little finger and partial paralysis of the middle and 
ring fingers. On the fourteenth day, at which period the history of 
the case closes, all these symptoms were rapidly disappearing. 1 

Nevertheless the fact is in the main as stated by Boyer ; and if so 
many cases can be found in which surgeons have succeeded at a late 
period, they are not probably in the proportion of one to five as com- 
pared with the failures ; but the failures have not received the same 
publicity. Nor indeed have all the severe accidents, such as violent 
inflammation, suppuration, gangrene, and even death, been faithfully 
declared. Denuce says he has been able to trace out five or six ex- 
amples in which, although the arm was reduced, grave accidents 
resulted, and Velpeau's patient actually died in consequence. 

Dixi Crosby, of New Hampshire, has treated two cases of ancient 
dislocation of the forearm backwards, by bending the elbow forcibly 
so as to break the olecranon process, after which the reduction was 
easily accomplished by extension. E. D. Mussey, of Cincinnati, has 
succeeded once in the same manner. In all these examples the elbow 
was restored to a very useful amount of motion. 2 

The dislocation being reduced, it may be a matter of prudence, some- 
times, to apply a right-angled splint, first carefully padded, to the 
palmar surface of the arm and forearm ; remembering, however, that 
considerable swelling will soon occur, and that it ought not therefore 
to be bandaged to the limb very tightly. At least once a day it should 
be removed, and the arm examined ; and in very few cases can it be 
necessary or judicious to continue its application beyond one week. 
At the same time, if there is any especial tendency in the radius to 
become displaced backwards, owing to a rupture of its annular liga- 
ment, this must be prevented, if possible, by a compress and bandage. 
Some surgeons regard these precautions as necessary in all cases, but 
I have seldom employed any splint or bandage whatever, nor have I . 
ever had reason to regret this omission. 

Finally, we are to place the arm in a sling, and adopt such measures 
as are calculated at first to reduce the inflammation; and at a very 
early day we ought to begin to move the elbow-joint, in order to 
prevent anchylosis. 

1 Westmoreland, Atlanta Med. and Surg. Journ., May, 1866. 

2 Crosby, Mussey, Trans. Anier. Med. Assoc, vol. iii. p. 357. 



DISLOCATION OF RADIUS AND ULNA OUTWARDS. 601 



Fig. 244. 



§ 2. Dislocation of the Radius and Ulna Outwards (to tee Radial 

Side. ) 

The large majority of outward dislocations of the forearm are in- 
complete; indeed, only nine examples of a complete dislocation have 
been collected by Denuce, including two seen by himself. Malgaigne 
has since added two more, making in all eleven cases. All these 
examples have occurred in the practice of French surgeons. So far 
as I am able to discover, no American or English surgeon has ever 
reported a single example. 

Incomplete dislocations must, therefore, in this case be regarded as 
typical; but even these are by no means frequent. 

Causes. — A careful examination of a large number of recorded ex- 
amples, and of those which have come under my own eye, renders it 
certain that a majority of these accidents result from a blow received 
directly upon the inner side of the forearm or upon the outer side of 
the humerus, or from the action of two forces pressing in an opposite 
direction. Of course those forces must act upon 
the bones somewhere in the neighborhood of the 
elbow-joint. Occasionally it has been produced 
by a fall upon the hand ; sometimes by a violent 
twist of the arm, as when the hand is caught in 
machinery ; and in other cases it has been found 
consecutive upon a dislocation backwards, being 
produced in the attempts made to accomplish re- 
duction of this latter form of dislocation. 

Pathology. — In most of the examples of simple, 
incomplete outward luxation of the forearm, the 
great sigmoid cavity of the ulna still embraces the 
lower end of the humerus, but instead of reposing 
upon the trochlea, it is carried outwards half an 
inch or more, so as to rest its central crest upon 
the depression which separates the condyle from 
the trochlea. If the annular ligament remains 
unbroken, the radius is displaced in the same di- 
rection and to the same extent, its head resting 
against and directly below the epicondyle. 

Occasionally, however, where the violence has 
been greater, the central crest of the great sigmoid 
cavity rests fairly upon the condyle, or upon the 
articulating surface of the humerus where the head 
of the radius was formerly applied, and the dislo- 
cation approaches more nearly to the character of 
a complete luxation. At the same time, owing perhaps to the resist- 
ance afforded by the skin, or some of the ligaments, the head of the 
radius may be thrown either forwards or backwards, so as to be out 
of line with the ulna. Such a displacement generally implies a rup- 
ture of the annular ligament. 

We have now only to suppose the action of a more considerable 
force in the same direction to render the dislocation complete; in 
39 




Most freqiient form of 
incomplete outward dislo- 
cation of the forearm. 



602 DISLOCATIONS OF THE RADIUS AND ULNA. 

which case the upper end of the radius is sometimes thrown com- 
pletely forwards, and its head may even be found resting in front of 
the ulna, occasioning an extreme pronation of the forearm and hand. 

The anconeus and brachialis anticus are the only muscles in either 
of these dislocations whose fibres are generally much disturbed ; the 
biceps and triceps being only made to traverse the articulation a little 
more obliquely. 

Denuce, Malgaigne, A. Cooper, and others have preferred to speak 
of the dislocation backwards and outwards as a distinct form or species 
of dislocation. I prefer to regard it as only a variety of the outward 
luxation, since it may, and no doubt often does, occur consecutively 
upon a simple incomplete outward dislocation ; and if the dislocation 
outward is complete, the bones of the forearm can scarcely fail to be 
drawn more or less upwards. Sometimes also it has been consecutive 
upon a simple backward dislocation, or upon unsuccessful attempts at 
reduction where the form of dislocation was originally backwards ; 
yet as it does not so naturally follow upon a complete backward dis- 
location as upon a complete outward luxation, I find sufficient reason 
for studying its mechanism in this place. 

The beak of the olecranon process not only, but a large portion of 
the body of this process now lies above and behind the condyle ; the 
brachialis anticus becomes more stretched if not actually torn, and the 
biceps is laid against the articulating surface of the humerus ; but the 
triceps becomes again relaxed, as in simple dislocation backwards 
and upwards. 

In all these dislocations the capsular ligaments are more or less ex- 
tensively torn, but the principal arteries and nerves do not generally 
suffer greatly if at all. 

Symptoms. —The forearm is usually flexed to about the same angle 
at which we have found it in dislocations backwards ; once I have 
found it nearly or quite straight ; occasionally it is flexed to a right 
angle. In all the cases seen by me the forearm has been pronated, 
and the elbow-joint has been very immovable. The most striking 
diagnostic sign, however, consists in the unnatural form of the elbow- 
joint, which is so remarkable as not to be easily misunderstood. The 
internal condyle of the humerus (epitrochlea) projects strongly to the 
inner side, leaving a deep depression below ; while upon the other 
side, the head of the radius with its cup-like extremity can be dis- 
tinctly felt, and made to rotate outside of its socket. The olecranon 
process, driven from its fossa, projects more or less posteriorly, and 
even the fossa itself may sometimes be plainly felt. 

A girl, twelve years old, had fallen upon the inside of her elbow, 
producing a dislocation outwards of the forearm. I saw her within 
half an hour. The forearm was bent upon the arm about fifteen de- 
grees, and immovably fixed. The head of the radius could be dis- 
tinctly felt external to and a little in front of the outer condyle, while 
the olecranon process of the ulna, which rested upon the back and 
outer surface of the humerus, was less distinctly felt than in the oppo- 
site arm. The inner condyle projected sharply to the inside, and the 



DISLOCATION" OF KADIUS AND ULNA OUTWAEDS. 603 

olecranon fossa was plainly felt with the fingers. The child was suf- 
fering very little pain. 

Seizing the wrist with my right hand and the lower end of the 
humerus with the left, and making moderate extension in these oppo- 
site directions, the bones easily, and after only a moment's effort, re- 
sumed their places. Her recovery was rapid and complete. 

James O'Neil, set. 16, was admitted to Bellevue Hospital in Dec. 
1865, with a dislocation caused by the kick of a horse, the blow 
having been received on the ulnar side of the forearm, near the elbow- 
joint. When he came under my notice the dislocation had existed 
three weeks. I found the head of the radius reposing upon the radial 
and posterior side of the humerus. The ulna was displaced one inch 
to the radial side. The forearm was not at all, or but very slightly 
flexed upon the arm. The natural deflection of the forearm to the radial 
side was a little exaggerated: forearm pronated: elbow-joint admitting 
of a little motion ; but motion caused great pain. 

This patient was not in my service, and I have not learned the result 
of the attempt at reduction. 

If the dislocation is complete, the position of the arm is usually the 
same, but the pronation of the hand is greater, and the projection of 
the inner condyle more striking. 

If now the bones, by a continuance of the original force, or by the 
action of the triceps, are drawn upwards also, the arm becomes a little 
more flexed, and the olecranon process more prominent, while the 
length of the whole limb is sensibly diminished. 

Prognosis. — In recent cases of incomplete outward luxation, and 
where no complications exist, the reduction is generally easily effected; 
and M. Thierry claims to have reduced an outward and backward 
luxation after eight months. A patient of whom Debruyn has spoken 
was not so fortunate. On the 16th of April, 1841, a lad, set. 18, fell 
upon the palm of his hand and dislocated both bones outwards and 
backwards ; on the following morning a surgeon attempted to reduce 
the dislocation, and the attempt was repeated on the next day by an- 
other surgeon ; but on the day following this last attempt, gangrene 
ensued in consequence of the great violence employed by the surgeons, 
and although the limb was amputated the patient died. The autopsy 
showed that both the brachial artery and the median nerve were torn 
asunder, and that the tendons of the biceps and brachialis anticus were 
slipped behind the outer condyle, probably having been thrown into 
this position during the violent twistings to which the arm had been 
subjected.' 

I have seen three examples of dislocation upwards and outwards 
which the medical attendants had failed to reduce. The first was in 
the case of a lad, Wm. Kinkaid, fourteen years old, who had fallen 
from a wagon and struck upon the palm of his left hand. The sur- 
geon who was immediately called made extension, and supposed that 
the reduction was accomplished. The lad was brought to me a few 
months after the accident. The arm was slightly flexed, and neither 

1 Denuce, op. cit., p. 103. 



604: DISLOCATIONS OF THE RADIUS AND ULNA. 

prone nor supine. There existed only a slight motion at the elbow- 
joint. I did not think it worth while to make any attempt at reduc- 
tion. Several years after this, in the month of February, 1859, I had 
an opportunity of examining the arm again. He had now recovered 
considerable motion in the joint, but he could not tie his cravat. 
Pronation and supination were perfect. 

In the second example, a lady, get. 33, had fallen upon the inside of 
her elbow, and reduction not having been accomplished, I found her, 
nine weeks after the accident, with scarcely any motion at the elbow- 
joint, and complaining of a numbness in the forearm and hand. 

The third instance of unreduced dislocation I will relate more at 
length. 

Francis Banfield, aged twenty -two years, a resident of Alleghany 
County, jKL Y., on the 31st of September, 1857, fell from the sweep of a 
threshing machine to the ground, a distance of about five feet, striking 
upon the palm of his hand, his arm being extended in front of him. On 
rising he found his arm forcibly flexed and abducted. He straight- 
ened it without difficulty, and it assumed the position it now occupies. 
A physician was called and saw the patient an hour and a half after 
the accident, who pronounced it a case of dislocation of the radius and 
ulna, and made efforts at reduction, which he continued from 8|- A. M. 
until 2 P. M., a period of five and a half hours, to no purpose, when 
he abandoned the attempt. During the attempt at reduction, the ex- 
tension was made at times with the arm flexed, and at others extended. 
At 9 P. M. another physician was called, who made efforts at reduc- 
tion until 3 A. M., upwards of six hours, at which time he also aban- 
doned the attempt. On the third day another physician, the patient 
being under the influence of ether, made efforts at reduction for twenty 
minutes, when he pronounced it in place, and applied a bandage. 
From the patient's account the arm was swollen to such an extent as 
to render this point difficult to determine. On the fifth day the first 
physician was called, and believing that he discovered a grating, 
pronounced it a fracture of the external condyle. 

Four months after the accident, when the patient applied to me, the 
limb presented the following appearances : " The forearm extended 
upon the arm ; looking at the limb along its radial margin we notice 
a gentle outward inclination of the forearm from the elbow down, but 
by manipulation this may be greatly increased ; the power of prona- 
tion and supination is not affected ; the inner condyle projects an 
inch to the ulnar side ; the head of the radius, completely removed 
from its socket, projects to an equal extent on the radial side. The 
top of the olecranon process is an inch higher than the top of the inner 
condyle, so that the radius and ulna are carried upwards as well as 
outwards." 

I believe that the external condyle was not broken, as in that case 
the arm would be permanently deflected outwards to a much greater 
extent. For, although this arm may be deflected outwards by the 
surgeon to an angle of 135°, still the degree of mobility which exists 
would be adverse to the supposition of its being a fracture of the 
external condyle. The condyles also can be plainly felt in their 



DISLOCATION OF RADIUS AND ULNA INWARDS. 605 

natural situations, which would not be the case if a fracture of the 
external condyle existed. The patient was advised not to submit to 
any further attempts at reduction. 

The following will serve as an illustration of a recent accident of 
this character : — 

John Collins, of Buffalo, set. 8, fell while wrestling, his companion 
falling upon his arm. I found the forearm slightly flexed, pronated, 
and both radius and ulna thrown over to the radial side and carried 
upwards. Pressing firmly upon the radius from the outside the bones 
assumed suddenly the position of a backward and upward dislocation, 
from which position they were readily reduced to their original sockets 
by simple extension. 

Treatment — In relation to the treatment of these accidents we have 
little to add to what has already been said of the treatment of dislo- 
cations backwards. The reduction, if effected at all, has generally 
been accomplished by moderate extension, or by extension combined 
with lateral pressure. If the head of the radius is in front of the 
humerus, or of the ulna, the hand should be first supined, and then 
the extension should be applied. In some cases the reduction has 
been effected by placing the knee in the bend of the elbow and flexing 
the forearm, while the surgeon was making extension from the hand. 

§ 3. Dislocation op the Radius and Ulna Inwards (to the Ulnar Side). 

This form of dislocation is much more rare than the dislocation 
outwards, a fact which may perhaps find a sufficient explanation in 
the peculiar form of the trochlea, the inner half of which rises much 
higher than the outer, forming thus an elevated inclined plane, over 
which the articulating surface of the ulna must rise before the dislo- 
cation can occur. 

Like the opposite dislocation, the typical form of the accident is 
that in which the displacement is incomplete ; indeed, no example of 
a complete inward dislocation has, we think, been yet recorded. 

Causes. — A fall upon the hand or forearm, a blow upon the radial 
side of the forearm near its upper end, or upon the ulnar side of the 
arm, near its lower end, a violent wrenching of the limb, are among 
the causes which may occasion this dislocation. 

Pathology. — The ridge which divides antero-posteriorly the greater 
sigmoid cavity of the ulna, having been driven over the elevated 
inner margin of the trochlea, falls down upon the epitrochlea, so as, 
in some sense, to embrace it instead of the trochlea ; while the head 
of the radius passes inwards also, and is made to occupy the trochlea, 
from which the ulna has escaped. Generally the head of the radius 
is found in the same line with the ulna (Fig. 245), but it may suffer a 
luxation and be found a little in advance of the ulna, or possibly a 
little in the rear. 

I choose also to regard the dislocation inwards and upwards as 
only a variety of the dislocation inwards ; in which form of the acci- 
dent the coronoid process of the ulna is thrust upwards above the 



606 



DISLOCATIONS OF THE KADIUS AND ULNA. 



epicondyle, and the head of the radius occupies the olecranon fossa, 
or rests upon the back of the humerus somewhere in this vicinity. 
In addition to the injury suffered by the ligaments and muscles, 
the ulnar nerve in both varieties of inward dislo- 
cation is peculiarly liable to contusion, in conse- 
quence of its being crushed between the olecranon 
process and the epitrochlea. 

Symptoms. — If the dislocation is only inwards, 
the olecranon process can be felt projecting upon 
the inner side, and completely concealing the epi- 
condyle ; while the head of the radius, having aban- 
doned its socket, may be felt indistinctly in the 
bend of the arm. The external condyle (epicon- 
dyle) is remarkably prominent. The forearm is 
generally more or less flexed, and the hand forci- 
bly pronated. The natural outward deflexion of 
the forearm is also lost, or it may be even inclined 
slightly inwards. This phenomenon is explained 
by the position of the epicondyle, upon which the 
greater sigmoid cavity now rests, allowing the ulna 
to overlap a little upon the humerus; rendering 
the forearm actually somewhat shorter along its 
ulnar margin, although the head of the radius may 
still occupy the summit of the trochlea. 

If the bones are displaced upwards as well as in- 
wards, a considerable shortening is declared, and 
the head of the radius may now be felt behind the 
trochlea, or over the olecranon fossa. In three of 
the four examples seen by Malgaigne, all of them 
ancient, the forearm was in a state of supination. Other surgeons have 
met with cases in which the forearm was supine, but they must be con- 
sidered as exceptions to the rule. 

The following example of this dislocation, unreduced after the lapse 
of fourteen years, is reported to me by Dr. T. H. Squier, of Elmira, 
1ST. Y. Thomas Cook, now in his nineteenth year, was four years and 
ten months old, when he fell from a pile of boards about as high as 
a man's shoulder. According to his statement, given at the time, his 
right arm caught between the boards, and, in falling, he turned a 
summersault. The mother, to whom the child immediately ran, 
grasped his arm which he said was broken, and found that it would 
roll and turn in various ways. When the surgeon arrived, three 
hours afterwards, the arm was very much swollen and the accident 
was supposed to be a fracture. At present flexion and extension are 
perfect. The forearm has an inward deflection of a hand's breadth 
more than the other. The power of pronation is complete, but the 
forearm and hand cannot be supinated entirely. The external con- 
dyle is very prominent, but the internal is almost hid by the olecranon, 
which projects inwards nearly as far as the point of the epicondyle. 
The finger can be laid in the olecranon fossa behind, and all the back 
part of the trochlea can be distinctly traced. By flexing the forearm 




Most frequent form of 
incomplete inward dislo- 
cation of the forearm. 



DISLOCATION OF RADIUS AND ULNA INWARDS. 607 

slowly, as it approaches a right angle, the tendon of the triceps may 
be felt, lodged, as it were, on the back part of the point of the epicon- 
dyle, and by continuing the flexion, the tendon suddenly slips over this 
point and places itself on the anterior aspect of the arm. When the 
forearm is fully flexed, the tendon is advanced full three-quarters of 
an inch in front of the epicondyle. The arm is very serviceable, but 
invariably pains him after a hard day's work. 

Prognosis. — Malgaigne was unable to reduce the dislocation in a 
recent case of incomplete internal dislocation, which came under his 
own notice. Triquet succeeded in a child seven years old, on the 
fifteenth day, after many trials ; but the movements of the elbow-joint 
were never restored. Dubruyn succeeded on the fifth day, but not 
without difficulty ; the case reported by Squier was mistaken for a 
fracture, and no attempt at reduction was made ; and in the only re- 
maining example which has been put upon record, the precise cha- 
racter of the accident having been determined by Yelpeau, reduction 
was easily accomplished, and on the eighth day the patient was 
dismissed. 1 

Of the four examples of inward and backward luxation seen by 
Malgaigne, not one was ever reduced ; but as the history of them all 
is not complete, it is by no means to be inferred that reduction could 
not have been easily accomplished, at least in some of them, at the 
first. Nor, with such imperfect details before us, can we understand 
fully what complications may have existed, such as would perhaps 
render these exceptional, rather than illustrative examples. 

One of these patients had a completely anchylosed elbow at the 
end of two years, but pronation and supination were preserved. In 
the case of another, however, even flexion and extension were as per- 
fect as in the normal condition. 

Treatment. — The indications of treatment are the same as in dislo- 
cations outwards, with only such slight modifications as the judgment 
of every surgeon must naturally suggest. I prefer to employ by way 
of illustration the example diagnosticated by Yelpeau. 

On the 10th of May, 1848, Alexandrine Guyot, aet. 22, entered the 
Hospital of La Charite, with an incomplete inward dislocation of the 
forearm which had just occurred. The hand and forearm were in a 
state of forced pronation, half-flexed, and the whole limb from the 
elbow downwards was deflected inwards. There were present also 
all the other usual signs of this dislocation, and Yelpeau had no doubt 
as to its true character. 

In order to accomplish reduction, one assistant made counter-exten- 
sion upon the arm, while a second made direct extension upon the 
forearm. At first the tractions were made in the direction of the fore- 
arm (flexed and prone), but gradually the arm was straightened and 
supinated. Then the surgeon, seizing with one hand the superior ex- 
tremity of the forearm, and with the other the inferior extremity of 
the arm, acted forcibly upon the two portions in opposite directions, 
and immediately the reduction was effected with a noise. 2 

1 Denuce, op. cit., pp. 154-156. 2 Ibid., p. 155. 



608 



DISLOCATIONS OF THE RADIUS AND ULNA, 



§ 4. Dislocation of the Radius and Ulna Forwards. 

Sir Astley Cooper, Yidal (de Cassis), and others have denied that 
this dislocation was possible without a fracture of the olecranon pro- 
cess ; but Monin, Prior, Yelpeau, Canton, 1 and Denuce have each re- 
ported one example, so that its existence may now be considered as 
established. Nevertheless, it is only as a result of very violent and 
extraordinary accidents, by which the forearm is forcibly flexed, or 
greatly extended, or twisted, or in some other unusual and indirect 
way the olecranon is placed in front of the humerus. 

The following is a summary of the facts in Yelpeau's case. Alex- 
andrine Carelli, set. 23, was knocked down by a carriage, on the first 
of July, 1848, the wheel passing over the right arm. The arm was 
found in a right-angled position, and it could neither be flexed nor 
extended ; the forearm was strongly supinated ; the projecting angle 
usually made by the olecranon process was replaced by the irregular 

Fig. 246. 




E. Canton's case of dislocation of the radius and ulna forwards. 

extremity of the humerus ; the forearm was shortened upon the arm ; 
the head of the radius resting in the coronoid fossa, and the olecranon 
process being also carried upwards and a little outwards. Reduction 
was easily accomplished, and the patient left on the nineteenth day, 
with only a slight remaining stiffness in the joint. 2 



» Dub. Quart. Journ. of Med. Sci., Aug. 1860. 
2 Denuce, op. cit., p. 110. 



DISLOCATIONS OF THE WEIST. 609 

Chapel has reported a case of dislocation forwards and outwards, 
which he readily reduced soon after it occurred, while Colson, Leva, 
and Gujot have each reported one example of swfr-luxation forwards, 
in which the extremity of the olecranon process has been found rest- 
ing upon the extremity of the humeral trochlea. 1 

Treatment. — If the dislocation is complete, and the forearm is short- 
ened and, flexed upon the arm, the reduction should be first attempted 
by violent flexion, or by flexion combined with extension from the 
wrist, and counter-extension from the lower portion of the humerus. 
If the dislocation is incomplete, and the forearm is extended upon the 
arm, the reduction may be readily accomplished by extension alone, 
or by moderate flexion. 



CHAPTEE X. 

DISLOCATIONS OF THE WRIST (RADIO-CAEPAL 
ARTICULATION). 

Eegarded as an accident of not unusual occurrence by Hippocrates, 
J. L. Petit, Duverney, Boyer, and by most if not all of the older writers, 
its frequency began to be questioned by Pouteau, and finally its ex- 
istence was almost absolutely denied by Dupuytren, who remarks: 
" I have for a long time publicly taught that fractures of the carpal 
end of the radius are extremely common ; that I had always found 
these supposed dislocations of the wrist turn out to be fractures ; and 
that in spite of all which has been said upon the subject, I have never 
met with, or heard of, one single well authenticated and convincing 
case of the dislocation in question." Dupuytren subsequently de- 
clared that he would not positively deny the possibility of the acci- 
dent, yet that " it must at least be admitted that the accident is an 
extremely rare one." Wishing to explain this infrequency, he says : 
" In examining the structure of the soft parts, one cannot fail to per- 
ceive that it is not the ligaments which prevent the displacement of 
the articular surface forwards, but that this effect is especially due to 
the multitude of flexor tendons, deprived as they are at this point of 
all the fleshy parts, and reduced to the simple fibrous tissue which 
compose them. These tendons are bound together beneath the ante- 
rior annular ligament of the wrist ; and thus offer so efficient a resist- 
ance that severe falls are insufficient to tear them through ; the hand 
is forced into a state of extreme tension, and the tendons are firmly 
applied on the anterior part of the radio-carpal articulation. If the 
extension is still further augmented, the wrist-joint is yet more closely 
clasped by these parts, and their power of resistance is incalculable ; 
I am convinced that a force equivalent to one thousand pounds weight 

1 Denuce, p. 120. 



610 DISLOCATIONS OF THE WKIST. 

would be inadequate to overcome it; and the known power of the 
tendo Achillis is sufficient to prove that this computation is not ex- 
aggerated. 

" The risk of dislocation backwards by a fall on the dorsal surface 
of the hand is equally precluded by the tendons of the extensor mus- 
cles. Their arrangement and relations at the back of the joint are 
similar; it is true they are not quite so strong; but we must admit 
that their power of resistance is very considerable, when we take into 
consideration how they are inclosed in sheaths as they cross beneath 
the posterior annular ligament of the wrist. I have not alluded to the 
ulna, for it has really little or nothing to do with these movements, as 
it does not articulate (directly) with the hand. 

" To sum up, then, the extreme rarity of dislocation forwards or 
backwards is owing to the obstacles opposed by the flexor or extensor 
tendons." 

The opinion of such a writer as Dupuytren, whose experience was 
very great, and who described only what he had seen, is always en- 
titled to profound respect ; yet it has been the practice of nearly all 
who have made any reference to his opinions in this matter to speak 
of them lightly, and not a few have falsely represented him as saying 
that such a. dislocation was " impossible." The fact is, that surgeons 
do still constantly mistake fractures of the lower end of the radius 
for dislocations, as my own personal observation can attest ; and not- 
withstanding examples have been reported by Bene, Marjolin, Padieu, 
Cruveilhier, Voillemier, Boinet, Malgaigne, Scoutetten, Bransby Cooper, 
Fergusson, W. Parker, and others, yet the whole number of cases for 
which the distinction is claimed is, to this day, so inconsiderable as 
only to establish the value and accuracy of Dupuytren's opinion that 
the " accident is an extremely rare one." But it is, perhaps, most re- 
markable that while very few of these supposed examples have been 
verified by an autopsy, in every instance in which the autopsy has 
been made, the dislocation has been found to be complicated with a 
fracture, generally of the lower extremity of the radius or of the 
styloid apophysis of the ulna. 

The existence of a complication, however, does not render the acci- 
dent any the less a dislocation, although it may render the diagnosis 
more difficult, and modify somewhat the indications of treatment. A 
knowledge of the fact, also, that such complications have always been 
observed in the autopsy may leave us in doubt as to what is the natu- 
ral history of a simple, uncomplicated dislocation, if, indeed, it does 
not warrant a suspicion that such a case never occurs. We shall, 
nevertheless, after a careful analysis of the cases as they have been 
reported, and by a consideration of the anatomy of this articulation, 
be able to determine with some degree of accuracy, perhaps, what 
are, or what ought to be the usual causes, signs, treatment, &c, of these 
accidents. 

Partial luxations have also been frequently described by surgeons. 
I have never met with an example, but the following case, related to 
me by the patient himself, I believe to have been a case in point. 

Lewis C, of Buffalo, set. 18, by a fall upon his hand, broke the left 



DISLOCATIONS OF THE CAEPAL BONES BACKWARDS. 611 

forearm below the middle, and at the same time, as he affirms, par- 
tially dislocated the carpal bones backwards. Dr. Spaulding, of 
Williamsville, IS". Y., took charge of the limb, and pronounced it a 
fracture with partial dislocation, and for more than a year after the 
accident the bones had a tendency to become displaced in the same 
direction. Whenever he attempted to lift even the weight of half a 
pound, with his hand supinated and his forearm extended horizon- 
tally, the lower end of the radius would spring suddenly forwards, 
and all power in the arm would be lost. When this happened, as it 
did quite often, he always reduced the bones himself, by simply push- 
ing upon them in the direction of the articulation. 

Fourteen years after the accident, I examined the arm and found it 
in all respects perfect, except that the forearm was shortened about 
one-third of an inch, which shortening was due, no doubt, to the 
overlapping of the broken bones. 

§ 1. Dislocations of the Carpal Bones Backwards. 

Causes. — The same casualty, namely, a fall upon the palm of the 
hand, which, as we have elsewhere noticed, produces frequently a frac- 
ture of the lower end of the radius, occasionally a dislocation of the 
radius and ulna backwards, at the elbow-joint, may also, it is believed, 
occasion sometimes a dislocation of the carpal bones backwards. In 
several of the cases reported, this cause has been assigned ; but in the 
only example of simple dislocation which has ever come under my 
notice, and which I have every reason to believe was a simple dislo- 
cation unaccompanied with a fracture, the carpal bones were thrown 
back by a fall upon the back of the hand. The following is a brief 
account of the case: — 

The Eev. Stephen Porter, of Geneva, N. Y., aet. 75, while walking 
with his son after dark, and holding in his right hand a satchel, slipped 
and fell. In the effort to save himself, and still retaining his grasp 
upon the satchel, his right hand struck the side-walk flexed, and in 
such a way as that the whole force of the fall was received upon the 
back of the hand and wrist, thus throwing the hand into a state of 
extreme flexion. In less than twenty minutes he was at my house. 
No swelling had yet occurred, and the moment I looked at the wrist 
I said to him, ''You have broken your arm;" so much did it resemble 
a fracture of the lower end of the radius. A farther examination led 
me to a different conclusion. The palmar surface of the wrist pre- 
sented an abrupt rising near the radio-carpal articulation, the summit 
of which was on the same plane and continuous with the bones of the 
forearm, and a corresponding elevation existed upon the dorsal surface 
terminating in the carpal bones and hand; the hand was slightly 
inclined backwards, but the fingers were moderately flexed upon the 
palm. To this extent the accident bore the features of a fracture of 
the radius; but the hand did not fall to the radial side; the projec- 
tions upon the palmar and dorsal surfaces were more abrupt than I 
had ever seen in a case of fracture, and which, if it were a fracture, 



612 DISLOCATIONS OF THE WRIST. 

would imply that the broken extremities had been driven off from 
each other completely ; the most salient angles of these projections 
were abrupt, but not sharp or ragged ; the styloid apophyses could be 
distinctly felt, and I was not only able to determine that they were 
not broken, but by observing their relations to the palmar and dorsal 
eminences, it was easy to see that these latter corresponded to the 
situation of the articulation. 

In addition to these evidences that I had to deal with a dislocation, 
and not a fracture, we had the testimony furnished by the reduction, 
which was not made, however, until by every possible means the 
diagnosis was definitely settled. Seizing the hand of the gentleman 
with my own hand, palm to palm, and making moderate but steady 
extension in a straight line, the bones suddenly resumed their places 
with the usual sensation or sound accompanying reductions. There 
was no grating, or chafing, or crushing, nor was the reduction accom- 
plished gradually, but suddenly. To test still further the accuracy 
of the diagnosis, I now pressed forcibly upon the wrist from before 
back, but without producing any degree of displacement, nor could 
any crepitus still be detected. No splint was applied, and on the fol- 
lowing morning Mr. Porter preached from one of the pulpits in the 
city, only retaining his arm in a sling. 

Sixteen months after the accident, Sept. 15, 1S58, this gentleman 
again called upon me, and I found the arm perfect in all respects, 
except that it was not quite as strong as before ; the lower extremity 
of the ulna was preternaturally movable, and occasionally he felt a 
sudden slipping in the radio-carpal articulation. 

Pathological Anatomy. — In the examples of compound or compli- 
cated dislocations, which alone have been exposed by dissections, the 
posterior and lateral ligaments have been found extensively torn, as 
also frequently the anterior ligament, with or without separation of 
the radial or ulnar apophyses; the extensor muscles torn up from the 

Fig. 247. 




Dislocation of the carpal bones backwards. (From Fergasson.) 

lower part of the forearm and displaced; the first row of the carpal 
bones lying underneath the tendons, and upon the bones of the fore- 



DISLOCATIONS OF THE CARPAL BOXES BACKWARDS. 613 

arm, sometimes having been carried directly upwards, sometimes up- 
wards and a little inwards, and at other times upwards and outwards; 
the arteries and nerves have occasionally escaped serious injury, but 
more often they have been displaced, bruised, or torn asunder. 

Such are, briefly, the pathological circumstances which may be 
supposed to exist, also, in a lesser or greater degree, in nearly all 
cases of simple dislocations. 

In compound dislocations, however, the muscles, or rather the ten- 
dons, are twisted, torn, and thrust aside, producing very extensive 
lesions among the deeper structures of the forearm and hand before 
the integuments can be made to yield. 

On the 2d of May, 1852, Silas Usher, set. 54, had his right arm 
caught between the bumpers of two cars, bruising the hand and dis- 
locating the carpal bones backwards, the radius and ulna being thrown 
forwards and pushed completely through the skin into the palm of the 
hand. Most of the flexor tendons had been merely thrust aside, but 
one or two were torn asunder ; the median nerve was torn off, but the 
radial and ulnar nerves were apparently uninjured, and there was 
no fracture. The patient being a temperate man, in perfect health, 
and the bones having been easily replaced by moderate extension, it 
was determined to make an effort to save the arm. The limb was 
therefore laid on a carefully padded splint, and cool water lotions dili- 
gently applied. Phlegmonous erysipelas began to develop itself on 
the third day; and on the ninth, gangrene having attacked the limb, 
I amputated a little above the middle of the humerus. On the four- 
teenth day hemorrhage occurred suddenly from the stump, and when 
I reached him he was pulseless and dying. 

The result demonstrated the error of the attempt to save the limb 
without resection of the lower ends of the bones of the forearm. 

Symptoms. — The usual signs have already been sufficiently stated 
in the example which we have given. The most important diagnostic 
marks are found in the abruptness of the angles formed by the pro- 
jecting bones ; the relation of these prominences to the styloid apophy- 
ses ; in the total absence of crepitus ; and in the reduction, which is 
accomplished easily, suddenly, and with a characteristic sensation. If 
a fracture complicates the accident, crepitus may also be present. It 
should be remembered, moreover, 
that when the styloid process of the Fi g- 248 « 

radius is broken, if the hand is 
moved backwards and forwards this 
process will move also, which might 
lead to the supposition that the ra- 
dius was broken higher up, and that 
it was not a dislocation at all. 

Prognosis.— In Compound dislo- Dislocation of the carpal bones backwards 

cations the prognosis is exceedingly (From skey.) 
grave, unless the surgeon determines 

to resort to amputation, or, what is generally much preferable, to re- 
section. In dislocations complicated with fracture of the posterior 




614: 



DISLOCATIONS OF THE WKIST, 



edge of the articulating surface of the radius (" Barton's fracture" 1 ), 
some difficulty may be experienced in retaining the bones in place ; 
but when this fracture does not exist, the posterior margin of the 
articulation, considerably elevated above its anterior margin, consti- 
tutes a sufficient protection against a reluxation in that direction. In 
all cases, also, complicated with fracture, even of an apophysis, intense 
inflammation and swelling are likely to follow, and the danger of a 
permanent anchylosis is greatly increased. 

Treatment. — Extension in a straight line has generally been found 
sufficient to accomplish the reduction ; to which may be added a slight 
rocking or lateral motion, if necessary. 

The reduction may be effected also by pressing the hand backwards, 
while the surgeon pushes the carpus downwards from behind and 
above, in the direction of the articulation. 

Unless a tendency to displacement exists, no splints or bandages 
of any kind ought to be applied, but it should be treated by rest and 
cool water lotions until all danger from inflammation has passed. 



§ 2. Dislocations of the Carpal Bones Forwards. 

The causes, mechanism, symptoms, pathology, treatment, &c, of this 

accident resemble in so many 
points those of the preceding 
dislocation, with only the differ- 
ences necessarily due to a change 
in the direction of the bones, that 
I find it not worth while to do 
more than to relate one single 
example contained in Bransby 
Cooper's edition of Sir Astley's 
work on Fractures and Disloca- 
tions. The case did not come 
under the observation of Mr. 
Cooper himself, but was related 
to him by Mr. Haydon, a sur- 
geon residing in London. It is 
especially interesting as furnish- 
ing an example of a dislocation 
of both wrists at the same moment, and from similar causes, but in 
opposite directions. 

A lad, aged about thirteen years, was thrown violently from a horse 
on the 11th of June, 1840, striking upon the palms of both hands 
and upon his forehead. The left carpus was found to be dislocated 
backwards, the radius lying in front and upon the scaphoides and 
trapezium. The right carpus was dislocated forwards, the radius and 
ulna projecting posteriorly, and the bones of the carpus forming an 
" irregular knotty tumor, terminating abruptly" anteriorly. 

A very careful examination was made to determine what parts 




Dislocation of the carpal bones forwards. (From 
Fergusson.) 



Philadelphia Medical Examiner, 1838. 



DISLOCATIONS OF LOWER END OF ULNA BACKWARDS. 615 

came in contact with the resisting force, but although the palms of 
both hands were extensively bruised, there was not the slightest 
bruise on the back of either hand. Nor were the gentlemen present 
able to find any evidence whatever that the dislocation was accom- 
panied with a fracture. "More- 
over," says Mr. Haydon, " we were Fi S- 25 °- 
strengthened in our opinion that 
this was a case of dislocation, un- 
attended with any fracture, because 
the dislocations appeared so per- 
fect ; the two tumors in each mem- 
ber so distinct; the reduction so «.■.♦■"*.!. , v * a m 

Dislocation of the carpal bones forwards. (From 

complete ; the strength ot the parts S key.) 
after reduction so great ; and, lastly, 

by the very trifling pain felt after reduction, for within an hour after, 
the patient could rotate the hand, and supinate it when pronated — 
this could not, we believe, have been done had there existed a frac- 
ture." 




CHAPTEE XI. 

DISLOCATIONS OF THE LOWER END OF THE ULNA 
(INFERIOR RADIO-ULNAR ARTICULATION). 

In connection with fractures of the lower end of the radius this 
accident is not very uncommon. I have myself met with it under 
these circumstances several times ; but without a fracture it is quite 
rare. Dupuytren met with but two cases in his long and extensive 
practice. Sir Astley Cooper does not record a single instance, and 
many surgeons affirm that they have never seen the dislocation in 
question. 

§ 1. Dislocations of the Lower End of the Ulna Backwards. 

To the eleven or twelve examples collected and referred to by 
Malgaigne, I am only able to add one case of ancient luxation seen 
by myself. 

Causes. — Duges mentions the case of a little girl in whom the acci- 
dent occurred in both arms, but at different periods, by being lifted 
by the hands. One of the patients seen by Desault, a child five years 
old, had the ulna dislocated backwards by extension accompanied with 
forced pronation, and in another example, cited by him, forced prona- 
tion alone, as in wringing wet clothes, was found to have been sufficient. 
In Hurteaux's case the patient had fallen upon her wrist. 

Pathological Anatomy. — Eupture of the synovial membrane (sacci- 
form ligament), and also of the ligament which binds the ulna to the 



616 DISLOCATIONS OF THE LOWEK END OF ULNA. 

cuneiform bone: the little head or lower extremity of the ulna aban- 
doning its socket in the radius, and being thrown backwards, or in 
some cases backwards and outwards so as to cross obliquely the lower 
end of the radius ; or it may incline inwards as well as backwards. 

Several examples are mentioned also in which the end of the bone 
has been thrust completely through the integuments. 

Prognosis. — In recent cases the reduction has generally been accom- 
plished without difficulty, and in only three or four instances has the 
bone become spontaneously displaced. 

Loder reduced the ulna after eight weeks, and Eognetta after sixty 
days. In the example to which I have already referred as having 
been seen by myself, the dislocation had existed twenty years, the 
accident having occurred in Ireland when the person was fifteen years 
old. When I examined the arm, July 21, 1850, the right ulna pro- 
jected backwards and a little outwards, about half an inch. He said 
he had been lame with it for several years, but the motions of the 
wrist-joint were now completely restored, and both pronation and 
supination were perfect. 

Symptoms. — The hand is usually fixed in a position midway between 
supination and pronation. Boyer, however, found the hand in a state 
of extreme pronation. The extremity of the ulna is felt and seen 
distinctly upon the back of the wrist, prominent and movable ; and 
the styloid process is no longer in a line with the metacarpal bone of 
the little finger; the fingers, hand and forearm are slightly flexed. 

Treatment. — The reduction may be accomplished by holding firmly 
upon the radius and at the same moment pushing the ulna forcibly 
toward its socket ; or by simply supinating the hand strongly. Some 
cases demand also extension and counter-extension. 

Generally the bone has been found to remain in its place without 
assistance, yet in three or four of the examples upon record the con- 
stant tendency to displacement when the pressure was removed has 
rendered it necessary to employ splints and compresses. 

§ 2. Dislocations op the Lower End of the Ulna Forwards. 

The dislocation forwards is said by Malgaigne to be more rare than 
the dislocation backwards. In addition to the nine cases collected by 
him, I have been able to add one reported by Parker, of Liverpool ; 
leaving, therefore, a difference of only three or four in favor of the 
luxation backwards; and not sufficient, I think, to warrant any posi- 
tive conclusions as to the relative frequency of the two accidents. 

While the dislocation backwards is usually caused by violent pro- 
nation of the hand, this dislocation is most often occasioned by violent 
supination. The hand is therefore generally found to be supinated 
forcibly, and the projection formed by the end of the bone is seen upon 
the front of the wrist instead of the back. 

By pushing the ulna toward its socket while an attempt is made to 
flex the hand, or by extension, supination, &c, it is made to resume its 
position readily. In the case reported by Parker, however, the re- 
duction was effected only while the hand was pronated. 



DISLOCATIONS OF THE CARPAL BONES. 617 

Parker's case, already referred to, is thus related : — 
"John Dalton, aged forty, applied to the hospital Aug. 9th, 1841, 
under the following circumstances : — 

" States that he is a carter, and falling down, the shaft of the cart 
fell upon his hand and forearm, in such a way as to supinate them 
forcibly. He complains of pain in the left wrist. The forearm is 
supinated, and cannot be pronated, the attempt causing much suffering. 
The wrist-joint can be flexed or extended without much pain. On. 
looking at the back of the wrist, the appearance is characteristic ; the 
natural prominence of the ulna is wanting ; an evident depression ex- 
ists, as if the lower end of the ulna had been dissected out ; it can be 
traced, however, on a plane anterior to the radius, its button-like head 
being distinctly felt under the flexor tendons. Several ineffectual and 
very painful attempts were made to accomplish the reduction, by 
pushing the head of the ulna into its natural situation. This was at 
last effected by seizing the hand to make extension (counter-extension 
being made at the elbow), then forcibly pronating the hand, at the 
same time pressing backwards the dislocated head of the bone with 
the fingers of the left hand. After persevering for a short time, the 
bone was felt to assume its natural position, the wrist acquired its 
usual appearance, and the ordinary movements of the joint could be 
readily performed. There was no tendency to redislocation, and the 
man was dismissed with directions to keep the bone quiet, and to 
foment it. He attended as an out patient for two or three days, after 
which, complaining of nothing but a little weakness in the part, a 
bandage was applied, and ordered to be worn for a short time." 1 



CHAPTEE XII. 

DISLOCATIONS OF THE CARPAL BONES (AMONG 
THEMSELVES). 

Bound together on all sides by strong ligaments, and enjoying 
only a very limited degree of motion among themselves, the carpal 
bones seldom become displaced except in gunshot wounds, or in con- 
nection with extensive lacerations and fractures of the neighboring 
parts. Simple dislocations, or rather subluxations of these bones do, 
however, occasionally take place, but so far as we have been able to 
ascertain, only in one direction, namely, backwards. 

The bones of the carpus, which are said occasionally to have suf- 
fered simple backward subluxation, are the semilunar, cuneiform and 
pisiform of the first row, and the magnum of the second row. 

Eicherand, the editor of Boyer's Lectures, says that he once met 

1 Parker, Amer. Journ. Med. Sci., April, 1843, p. 470 ; from Lond. and Edin. Month. 
Journ. Med. Sci., Dec. 1842. 
40 



618 DISLOCATIONS OF THE CARPAL BONES. 

with a subluxation of the os magnum backwards, of which he has 
given us the following account : " Mrs. B., in a labor pain, seized vio- 
lently the edge of her mattress, and squeezed it forcibly, turning her 
wrist forwards ; she instantly heard a slight crack, and felt some pain, 
to which her other sufferings did not allow her to attend. Fifteen 
days afterwards, happily delivered, and recovered by the care of Pro- 
fessor Baudelocque, she showed her left hand to this celebrated ac- 
coucheur, and expressed her disquietude about the tumor which 
appeared on it, especially when much bent. I was called to visit the 
lady. I found that this hard circumscribed tumor, which disappeared 
almost totally by extending the hand, was formed by the head of the 
os magnum, luxated backwards ; I replaced it entirely by extending 
the hand, and making gentle pressure on it. As the affection did not 
impede the motion of the part, as the. tumor disappeared on extend- 
ing the hand, and as it would have been but little apparent in any 
state of the hand had Mrs. B. been more in flesh, I advised her not 
to be uneasy about it, and to apply no remedy to it." 1 

Eicherand adds also that Boyer and Chopart had each met with 
the same dislocation. 

Bransby Cooper saw the os magnum displaced backwards in a 
stout, muscular young man by a fall upon the back of the hand when 
in extreme flexion. The hand remained slightly bent, and the pro- 
jection of the os magnum was very distinct. Eeduction was attempted 
Toy extending the whole hand, at the same time making pressure upon 
the displaced bone ; this not succeeding, extension was made from the 
middle and forefingers only, while pressure was kept up on the os 
magnum, when suddenly the bone resumed its natural position. On 
flexing the hand, however, the dislocation was immediately repro- 
duced; and it became necessary to apply a compress and splint. For 
several days after, he was in the habit of pushing it out by flexing 
the hand, in order that the young men at Guy's Hospital might see its 
reduction ; which was always easily accomplished by simply pushing 
upon it. 

Sir Astley says that both the os magnum and cuneiforme are some- 
times thrown a little backwards, from simple relaxation of the liga- 
ments, producing a great degree of weakness, so as to render the hand 
useless unless the wrist be supported ; and he mentions the case of a 
young lady in whom the os magnum was thus displaced and who was 
obliged to give up her music in consequence ; for when she wished to 
use her hand she was compelled to wear two short splints, made fast 
to the back and forepart of the hand and forearm. Another lady, 
whose hand was weak from a similar cause, wore, for the purpose of 
giving it strength, a strong steel chain bracelet, clasped very tightly 
around the wrist. 2 

Gras has described a dislocation of the pisiform bone, 3 and Fergus- 
son says he has known an example in which this bone was detached 

1 Ricberand, Bojer's Lectures on Diseases of Bones, Amer. ed., 1805, p. 261. 

2 Sir A. Cooper, op. cit,, p. 435. 

5 Note to Chelius, by South, op. cit., p. 234. 



DISLOCATION OF THE METACAKPAL BONES. 619 

from its lower connections by the action of the flexor carpi -ulnaris. 1 
Little benefit, he thinks, can be expected from any attempts to keep 
it in place when it is dislocated, nor is its displacement of much con- 
sequence. Erichsen thinks he has seen a dislocation of the os lunare 
produced by a fall upon the hand when forcibly flexed. By exten- 
sion and pressure it was easily replaced, but when the hand was flexed 
the dislocation was immediately reproduced. 2 

Notwithstanding that Sir Astley, Miller, and others have taught 
that the cuneiform bone is liable to displacement, and that South has 
affirmed the same of the unciform, I have found no account of an ex- 
ample of simple dislocation of single carpal bones except in the cases 
of the os magnum, pisiformis, and lunare, as above mentioned. 

Maisonneuve has reported an example of simple dislocation, with- 
out wound of the integuments, at the middle carpal articulation. A 
man had fallen forty feet, and was carried dying to the Hotel Dieu. 
The symptoms were almost precisely those of a dislocation of both 
rows of the carpal bones backwards. The reduction, was not accom- 
plished during life, but after death a simple effort of traction was 
sufficient to replace the bones. The dissection showed that the bones 
of the second row were almost completely separated from those of the 
first, upon which they were overlapped backwards. A small frag- 
ment of both the scaphoides and cuneiform remained attached to the 
second row, but with this exception, the separation was complete. 3 



CHAPTEE XIII. 

DISLOCATION OF THE METACARPAL BONES (AT 
THE GARPO-METACAEPAL ARTICULATIONS). 

The metacarpal bone of the thumb may be dislocated either back- 
wards or forwards. The former is the most frequent ; and it is pro- 
duced generally by a fall upon the thumb, which throws it into a state 
of extreme flexion : it has also been occasioned by a force acting in 
an opposite direction, as when a flask of powder is exploded in the 
palm of the hand, or a blow is received upon the extremity and palmar 
aspect of the last phalanx. 

The dislocation may be partial or complete. In the few examples 
of partial dislocation which have been recorded, the position of the 
finger has been either moderately flexed or straight, and the signs of 
the accident have been occasionally so obscure as to have led to an 
error in the diagnosis, and the luxation has remained unreduced. 
When the dislocation is recognized, reduction is in most cases easily 



Fergusson, op. cit., p. 190. 

Erichsen, Science and Art of Surg., Amer. ed., 1859, p. 259. 

Maisonneuve, Malgaigne, op. cit., from Mem. de la Soc. de Chirurg., t. ii. 



620 DISLOCATION" OF THE METACARPAL BONES. 

accomplished by pressure, combined with extension ; after which it 
is sometimes necessary to apply a splint to maintain the apposition. 
If the reduction is not accomplished, the joint is permanently maimed. 

Complete backward luxations are more frequent than incomplete, 
and are produced by the same class of causes ; generally by a fall upon 
the palmar surface of the thumb. 

The symptoms are sufficiently clear, although the position of the 
thumb is not always the same. It has been found perfectly straight, 
without any inclination either way, or flexed more or less, with the 
metacarpal bone also inclined inwards toward the palm. The motions 
of the joint are interrupted, and the proximal extremity of the meta- 
carpal bone riding upon the back of the trapezium, projects sensibly 
in this direction, and the trapezium is also felt unusually prominent 
under the thenar eminence. The overlapping varies from a line or 
two to three-quarters of an inch. In the patient mentioned by Bour- 
guet, the head of the metacarpal bone almost reached the styloid pro- 
cess of the radius. 

The reduction is to be effected by extension alone, or by extension 
with moderate pressure. 

In two of the examples reported, although the reduction was accom- 
plished very easily, the dislocation was reproduced when the extension 
ceased, and it became necessary to apply splints. Malgaigne did not 
observe, in the case seen by him, any such tendency to displacement. 

In the case of Bourguet's patient the reduction was never accom- 
plished, although the attempt was made on the second day by a sur- 
geon, and repeated after about two months by Bourguet himself. 

Fergusson, who has met with several of these dislocations, says that 
he has seen even a splint and roller fail of keeping the bones in place ; 
and he recommends, for the purpose of security, that the splint should 
extend some distance upon the forearm. 

Sir Astley Cooper says that, in the cases of this accident which he 
has seen, the metacarpal bone of the thumb has been thrown inwards, 
between the trapezium and the root of the metacarpal bone supporting 
the forefinger; forming a protuberance toward the palm of the hand; 
the thumb has been bent backwards, and adduction was impossible. 

This distinguished surgeon cites no examples, nor are we able to 
find upon record an instance of complete inward dislocation of this 
bone, such as Sir Astley has described. 

Tidal (de Cassis) believes that he has met with a partial forward dis- 
location, which he reduced readily, but the patient having removed 
the retentive means, the dislocation was reproduced and the bone was 
not again replaced. 1 

Malgaigne has collected only three examples of a dislocation of 
either of the other metacarpal bones. One, observed by Bourguet, 
was a dislocation forwards of the metacarpal bone of the index finger, 
having been caused by a great force applied to the back of the phalanx 
near the carpus. Eeduction was effected by extension and pressure, 
the bone resuming its place insensibly and not suddenly. With the 

1 Vidal (de Cassis), Traite de Pathologie Externe, etc., 3d Paris ed., t. ii. p. 564. 



FIEST PHALANX OF THE THUMB BACKWARDS. 621 

aid of splints it was retained in position, and the cure was perfect. 
The second, seen- by Koux, was a backward luxation at the carpo- 
metacarpal articulation of the second, or great finger, produced by an 
explosion in a mine. By pressure made directly upon the projecting 
bone he was unable to reduce it, but by uniting pressure with exten- 
sion from the finger, he succeeded readily. After the reduction was 
effected, it was noticed that when the hand was straightened the bone 
became reluxated, but that it was easily kept in place when the hand 
was flexed. The third example (occurring in the same joint), men- 
tioned by Malgaigne, occasioned by a fall upon the clenched hand, 
was probably incomplete, and Malgaigne is not quite certain that it 
was not a fracture. 

In April, 1849, Stephen Peterson, set. 24, was admitted into the 
Buffalo Hospital of the Sisters of Charity, with a partial dislocation 
backwards of the proximal ends of the metacarpal bones of the index 
and great fingers of the right hand ; produced, as he affirms, by striking 
a man with his clenched fist, about one year previous. He says that 
he called upon a surgeon immediately, but he was unable to keep the 
bones in place. The projection was very manifest at the time of my 
examination, and the hand had never recovered the power of grasp- 
ing bodies firmly. 

During the same year I found in the hospital a precisely similar case, 
in the person of Francis M'Coit, set. 32, a sailor, which had occurred 
four years before, in consequence of a blow given with his fist. The 
same bones were partially displaced backwards, and remained unre- 
duced. This man had also consulted a surgeon soon after the injury 
was received. 

In both of the above examples I instituted a careful examination to 
determine whether it was not the bones of the carpus thus displaced ; 
but the result was conclusive as to the nature of the accident, and I 
have obtained casts of both in order to illustrate partial dislocations 
of the metacarpal bones. 



CHAPTEK XIV. 

DISLOCATIONS OF THE FIRST PHALANGES OF THE 
THUMB AND FINGERS (AT THE METACARPOPHA- 
LANGEAL ARTICULATIONS). 

§ 1. Dislocations of the First Phalanx of the Thumb Backwards. 

This bone may be dislocated backwards or forwards, but most fre- 
quently the dislocation is backwards. I have met with the backward 
dislocation seven times, and the forward twice. 



622 OF FIKST PHALANGES OF THU3IB AND FINGEES. 



Fig. 251. 




Dislocation of the first 
phalanx of the thumb back- 
wards. 



The backward dislocation is occasioned generally by a fall or blow 
upon the distal end and palmar surface of the 
thumb ; the proximal extremity of the first pha- 
lanx slidiug back upon the distal extremity of 
the metacarpal bone, and standing off from it at 
an angle, the last being again flexed upon the 
first phalanx ; meanwhile the distal end of the 
metacarpal bone is seen projecting strongly in the 
palm of the hand. (Fig. 251.) 

These are the usual signs which characterize 
this accident, and they are always sufficiently 
diagnostic. In a few cases, however, the pha- 
langes have been found extended upon the meta- 
carpal bone in almost a straight line. I have 
twice found them in this position. 

The reduction is sometimes, in recent cases, 
accomplished with great ease, as the following 
examples will illustrate. 

A servant girl, est. 25, fell down a flight of steps Nov. 15, 1850, 
striking upon the inside of her right hand and thumb. When I saw 
her, only a few minutes afterwards, I found the first phalanx standing 
back almost at a right angle with the metacarpal bone, and the second 
phalanx also flexed to a right angle with the first. Assisted by my 
pupil, Mr. Boardman, .the reduction was effected in about twenty 
seconds, by bending the first phalanx farther back, and at the same 
moment pressing the proximal end of this phalanx forwards in the 
direction of the joint. Without employing great force, the reduction 
took place suddenly and with a snap. Very little swelling followed, 
and in three weeks she was able to use her needle without incon- 
venience. 

Michael Wolfe, set. 35, fell from a height, causing a fracture of his 
left arm, and a dislocation of his right thumb backwards. I saw him 
within two hours after the accident. The thumb was much swollen, 
and its position the same as in the case just described. Although 
Wolfe was a strong, muscular man, the reduction was accomplished in 
a few seconds by applying over the last phalanx the Indian toy called 
a "puzzle," and making extension in a straight line, while an assistant 
made counter-extension from the hand and wrist. The use of the joint 
was soon completely restored. 

Examples, however, are constantly occurring, which are only re- 
duced after long-continued and painful efforts, or which, indeed, com- 
pletely exhaust the patience and baffle the skill of the most experienced 
surgeons. 

Mary J. S., set. 23, fell upon her right hand with her fingers and 
thumb extended, in Sept. 1853, and dislocated this bone backwards. 
A young surgeon attempted to reduce the dislocation half an hour 
after the accident, by the same manoeuvre adopted by myself success- 
fully in the case of the servant girl ; only that he made extension upon 
the last phalanx at the same moment. The surgeon believes that the 



FIEST PHALAXI OF THE THUMB BACKWARDS. 623 

bone was reduced, but one week later lie found it displaced, and, as 
he believes, reduced it again. The same thing occurred a third time. 

Six months after this, the girl consulted me to ascertain what could 
be done for her relief. The thumb occupied the usual position, and 
admitted of no motion except at the carpo-metacarpal articulation. 

It is quite probable that the dislocation was never reduced, an error 
which, if it did occur, might easily be excused, when we remember 
that from the first the thumb was greatly swollen. 

In May, 1848, having been called to see Gr. H., who had attempted 
suicide by cutting his throat, my attention was arrested by the 
appearance of his left thumb, and which I found to be occasioned by 
an ancient dislocation of the first phalanx backwards. The accident 
had occurred, he afterwards told me, twelve years before, in conse- 
quence of a fall while wrestling. A very respectable country surgeon 
was called, and made three several attempts to reduce it, but failed. 

The several bones of the thumb occupied their usual positions, that 
is to say, the positions which they usually occupy in this dislocation, 
yet notwithstanding the almost complete anchylosis of the phalangeal 
articulations, and the awkward encroachment of the distal end of the 
metacarpal bone upon the palm, the hand was quite useful. 

In Sept. 1864, 1 found in my service at the Charity Hospital (Black- 
well's Island), New York, an unreduced dislocation of this kind in a 
girl. The surgeons had tried to reduce it, but had failed. 

On the 25th of July, 1857, Catharine Ernst was brought to me, by 
her parents, having a dislocation of the first phalanx of the right hand, 
which had already existed some days, and upon which several un- 
successful attempts at reduction had been made. The dislocation was 
backwards, but the phalanges, instead of standing at an acute or right 
angle with each other and with the metacarpal bone, as is usually the 
case, were in a straight line with each other and parallel with the 
metacarpal bone. Whether this phenomenon existed from the first, 
or was due to the efforts already made at reduction, I could not deter- 
mine, but the same thing has been noticed occasionally by other sur- 
geons. The first phalanx, moreover, instead of being placed directly 
behind the metacarpal bone, occupied a position upon its back a little 
to the radial side of the centre. 

During quite half an hour I made continued and varied attempts 
to reduce the bone, by extension, by forced dorsal flexion, and by 
pressing the upper end of the first phalanx in the direction of the 
joint while pressure was made against its lower end so as to bring it 
into dorsal flexion, and finally by calling to my aid the " puzzle" and 
chloroform, but all to no purpose. 

One week later I repeated these efforts, and with no better success. 
The parents peremptorily refused to allow me to cut the lateral liga- 
ments or flexor tendons, so the bone remains unreduced. 

In the following case the relative position of the bones was the 
same as in the preceding case, but the reduction was not difficult. 

Bernard Lawler, set. 10, was admitted to Belle vue Hospital in Jan. 
1864, with a fracture of the femur and other severe injuries. The 
dislocation of the thumb was not noticed until the ninth day. The 



624 OF FIEST PHALANGES OF THUMB AND FINGERS. 

reduction was then easily accomplished, in presence of the class of 
medical students, by forced backward flexion. 

Surgical writers have recorded, from time to time, a great many 
cases in which it has been found difficult or impossible to effect re- 
duction ; and it is asserted upon the authority of Bromfield, quoted 
by Hey, that the extending force has been increased to such an amount 
as to tear off the last phalanx without having succeeded in reducing 
the first ; but while surgeons have united in their testimony as to the 
exceeding obstinacy of a large proportion of these dislocations, they 
are far from being agreed as to the source of the difficulty. 

Sir Astley Cooper finds a sufficient explanation in the six short and 
powerful muscles which are inserted into the first and last phalanx, 
and especially in the flexors. 1 Hey believes the resistance to be in 
the lateral ligaments between which the lower end of the metacarpal 
bone escapes and becomes imprisoned. Ballingall, Malgaigue, Erich- 
sen, and Vidal (de Cassis) think the metacarpal bone is locked between 
the two heads of the flexor brevis, or rather between the opposing 
sets of muscles which centre in the sesamoid bones, as a button is 
fastened into a button-hole. Pailloux, Lawrie, Michel, Leva, Blechy, 
and Eoser affirm that the anterior ligament being torn from one of its 
attachments falls between the joint surfaces and interposes an effectual 
obstacle to reduction. Dupuytren ascribes the difficulty to the altered 
relations of the lateral ligaments, which are naturally parallel to the 
axis of the metacarpal bone, but which are now placed at a right 
angle ; to the spasm of the muscles, and to the shortness of the mem- 
ber, in consequence of which the force of extension has to be applied 
very near to the seat of the dislocation. Lisfranc found in an ancient 
luxation the tendon of the long flexor so displaced inwards and en- 
tangled behind the extremity of the bone as to prevent reduction. 
Deville discovered in an autopsy a similar displacement of this tendon 
outwards. Wadsworth has made the same observation. 2 

The modes of reduction practised and recommended by these 

different surgeons are as diversified and 
Fig- 252 - irreconcilable as their views of the me- 

chanism and pathological anatomy of the 
accident. 

Sir Astley Cooper recommends that 
extension shall be made by bending the 
thumb toward the palm of the hand, to 
relax the flexor muscles as much as possi- 
ble ; and then by fastening a clove hitch 
upon the first phalanx, previously covered 
with a piece of soft leather, the extension 
is to be continued, only inclining the 
thumb a little inwards toward the palm 
ciove Mtch. of the hand. If these means fail after 

1 Lawrie, of Glasgow, says that Sir Astley in a conversation with him declared that 
the " sesamoid bones" were the sources of the difficulty. See Amer. Journ. Med. 
Sci., vol. xxii. p. 230, with observations and experiments by Lawrie. 

2 Wadsworth, Amer. Med. Times, Feb. 13, 1864, p. 77. 




FIKST PHALANX OF THE THUMB BACKWARDS. 625 

having been continued a considerable length of time, he advises that 
a weight shall be suspended to the thumb, passing over a pulley. 
Finally, in the event of the failure of this method also, Sir Astley 
thought that no further attempts should be made, and especially that 
no operation for the division of these parts is justifiable. 

Lizars and Pirrie adopt the views of Sir Astley with little or no 
qualification. 

Fig. 253. 




Sir Astley Cooper's method of reducing dislocations of the thumb, with pulleys. 

Charles Bell proposed flexing the joint, employing also at the same 
time pressure ; and in obstinate cases he advised subcutaneous section 
of the lateral ligaments with a small knife, a method which has since 
been practised successfully by Liston, Eeinhardt, Gibson, of Philadel- 
phia, Parker, of New York, and others. Syme and Lizars justify the 
practice in certain cases. Hey declared that neither extension nor 
flexion was useful, but that the bones could be best brought into place 
by pressure alone. 

Eoser, from his experiments upon the cadaver, concludes that the 
dislocated phalanx must first be bent forcibly backwards, or into the 
position termed by some writers dorsal flexion, so as to throw the head 
of the phalanx forwards upon the articulating surface of the metacarpal 
bone. Parker, of New York, in his notes to the American edition of 
Samuel Cooper's work ; recommends the same procedure. 

Yidal (de Cassis) recommends also that the extension should be 
made first backwards, so as to increase the displacement of the first 
phalanx in this direction, and to throw forwards its articular surface 
in the direction of the articular surface of the metacarpal bone. 

This method, namely, dorsal flexion as the first and most essential 
part of the manoeuvre, seems to have met with more general approval 
than any other, and the following observations, made by the venerable 
Eeuben D. Mussey, of Cincinnati, illustrate the general practice among 
American surgeons at this day. 

" I tilt the dislocated phalanx up until it stands upon its articu- 
lating end, place both forefingers so as to hold it in that position, and 
at the same time press against the distal extremity of the metacarpal 
bone, make firm pressure with the thumbs against the base of the 
dislocated phalanx, and slide it into its place, which can generally be 
accomplished with ease. 

" More than twenty-five years ago, the chairman of this committee, 
from attention to the mechanism of the metacarpo-phalangeal joint of 
the thumb, convinced himself that the principal impediment to the re- 
duction of the first phalanx from backward displacement is the short 



626 OF FIRST PHALANGES OF THUMB AXD FINGERS. 

flexor of the thumb, between the two portions of which (lying close 
together where they are fastened to the sesamoid bones) the head of 
the metacarpal bone has been thrust, the contracted part or neck of 
this bone lying firmly grasped by "them. Fifteen years ago, a case 
occurred of this dislocation which he could not reduce in the ordinary 
way. A subcutaneous division of one of the heads of this muscle was 
made with an iris knife, and the reduction was accomplished with the 
greatest ease. 

"Last year, another case occurred, in which we failed of reduction 
by Dr. Crosby's method, which we believe to be the best, and the 
subcutaneous division of both heads of the muscle was made, and the 
reduction instantly effected. The punctures were covered with collo- 
dion, and the thumb supported by a splint. As the patient was in- 
temperate, entire abstinence from liquor and the adoption of a light 
diet were enjoined. Neither pain nor inflammation followed, and a 
month afterwards the joint had free motion. After the intemperate 
and irregular habits were resumed, the joint in a few weeks was found 
anchylosed. In these cases, the knife, in the subcutaneous operation, 
was carried down to the metacarpal bone, so far behind its head as to 
preclude the possibility of mistaking the lateral ligaments for the 
muscles. The ligaments are very short, and inserted close to the 
articular surfaces, and are probably, one or both, ruptured in this dis- 
location." 1 

Dr. J. P. Batchelder, of New York, in a paper read before the New 
York Medical Association in 1856, says: "The surgeon should take 
the metacarpal portion of the dislocated thumb between the thumb 
and finger of one hand, and flex or force it as far as may be into the 
palm of the hand, for the purpose of relaxing the muscles connected 
.with the proximal end of the phalanx, particularly the flexor brevis 
pollicis. He should then apply the end of the thumb of this hand 
against the displaced extremity of the dislocated phalanx for the pur- 
pose of forcing it downwards, and at the same time grasp the displaced 
thumb with his other hand, and move it forcibly backwards and for- 
wards, as in strongly forced flexion and extension, the pressure against 
the upper extremity of the first phalanx being kept up. In this way 
the dislocated bone may be made to descend, so as to be almost or 
quite on a line with the articulating surface of the metacarpal bone, 
when the thumb may be forcibly flexed, and, if it be not reduced, as 
forcibly extended, and brought backwards to a right angle with the 
metacarpal bone, when, if the downward pressure, with the thumb 
placed as before, directed for that purpose, has been continued (which 
thumb, by maintaining its position, acts as a fulcrum, as well as by its 
pressure), the bone will slip into its place, and the reduction be effected 
in less time than has been spent in describing the process." 3 

Six successive cases of treatment by this method are mentioned in 
the American Journal of Medical Sciences for April, 1858 ; one by 
Kickard, one by Morgan, two by Cutter, and two by Crosby. 

1 Mussey, Trans. Amer. Med. Assoc, vol. iii. 1850, p. 357. 

2 Batchelder, New York Journ. Med., May, 1856, p. 340. 



FIRST PHALANX OF THE THUMB BACKWARDS. 



627 



By those who have regarded extension as an important element in 
the reduction, various instruments have been devised for the purpose 
of obtaining a secure hold upon the dislocated member. Sir Astley 
Cooper, as we have already seen, recommended the sailor's clove 
hitch; 1 Lawrie advises that the thumb shall be thrust into the open 
handle of a large door key ; 2 Charriere and Luer, of Paris, have each 
invented forceps, so constructed with fenestra and straps, as that when 
the blades are closed the member is held very firmly in its grasp. 
Eichard J. Levis, of Philadelphia, recommends "a thin strip of hard 
wood, about ten inches in length and one inch, or rather more, in width. 

Fig. 254. 




Levis's instrument for reduction of dislocations of fingers or the thumb. 

One end of the piece is perforated with six or eight holes. The oppo- 
site end is partly cut away, forming a projecting pin, and leaving a 
shoulder on each side of it. Towards this end of the strip, a sort of 
handle shape is given to it, so as to insure a secure grasp to the ope- 
rator. Two pieces of strong tape or other material, about one yard in 
length, are prepared. One of these is passed through the holes at the 
end of the strip, leaving a loop on one side. The other tape is passed 
through another pair of holes, according as it may be a thumb or finger 
to which it is to be applied, or varied to suit the length of the finger, 
leaving a similar loop. If a dislocated thumb is to be acted on, the 
second tapes should be passed through the holes nearest the first. The 
ends of each separate tape are then tied together. 

" To apply this apparatus, the finger is passed through the loops. 
The loop nearest the first joint is then tightened by drawing on the 

Fig. 255. 




Levis's instrument applied to the first finger. 

tape, which is then brought along the strip to the opposite end, across 
one of the shoulders, and secured by winding it firmly around the 
projecting pin. The other tape is tightened in a like manner, cross- 

1 Op. cit., p. 561 ; also Bost. Med. and Surg. Journ., Oct. 1, 1857. 

2 Lawrie, Am. Journ. Med. Sci., vol. xxii. p. 229. 



628 OF FIRST PHALANGES OF THUMB AND FINGERS. 

ing the other shoulder, and winding around the pin in an opposite 
direction, when, for security, the ends of the tapes are finally tied 
together." 1 

This apparatus enables the operator to apply both extension and 
flexion or leverage in any direction. The proximal end of the pha- 
lanx may be lifted, or even rotated so as to allow one side of the bone 
to approach the socket before the other. 

Malgaigne describes an apparatus invented by Kirchoff, which is 
very simi]ar to, yet not quite so complete, as this of Levis. 

In the April number of the Buffalo Medical Journal, for 1847, I 
have described an instrument, or rather a toy, in my possession, which 
I suggested might be useful for the purpose of making extension 
upon dislocated fingers ; and which, as will be seen by a reference to 
one of the cases already reported in this chapter, I have since applied 
successfully. It is made by the Indians, and may always be obtained 
during the watering season, at the Indian toy shops at Niagara Falls. 
The Indians call it a "puzzle," and know no other use for it than to 

Fig. 256. 




Indian "pnzzle," employed for the reduction of dislocations in small joints. 

fasten it upon the thumb or finger of some victim, and then pull him 
about until he begs to be released. 

The "puzzle" is an elongated cone of about sixteen or eighteen 
inches in length, made of ash splittings, and braided ; the open end of 
the cone being about three-fourths of an inch in diameter, and the 
opposite end terminating in a braided cord. When applied to the 
finger, it is slipped on lightly, forming a cap to the extremity, and to 
half the length of the finger, but on traction being made from the 
opposite end, it fastens itself to the limb with a most uncompromising 
grasp. If constructed of appropriate size and of suitable materials, 
it becomes the more securely fastened in proportion as the extension 
is increased ; yet, applying itself equally to all the surfaces, it inflicts 
the least possible pain and injury upon the limb. When we wish to 
remove it, we have only to cease pulling, and it drops off spontane- 
ously. 

Dr. Holmes says that the same instrument is made by the Indians 
of Maine, and that several years ago Dr. Davis, of Portland, brought 
one to Boston, and showed it to the Society for Medical Improvement, 
suggesting that it might be used in the same manner which I have 
recommended. 2 

Finally, in some compound dislocations it would be better not to 

1 Levis, Amer. Jonrn. Med. Sci., Jan. 1857, p. 62. 

2 Trans. Am. Med. Assoc, vol. i. p. 267. 



FIRST PHALANX OF THE THUMB FORWARDS. 629 

attempt the reduction of the dislocation until resection has been prac- 
tised. Samuel Cooper relates a case in which the reduction was fol- 
lowed by inflammation and death within a week after the accident, 
and ISTorris, of Philadelphia, mentions an instance which came under 
his observation, where violent inflammation and tetanus followed the 
reduction. 1 Eoux, Evans, Wardrop, Grooch, Sir Astley Cooper, aod 
many other surgeons, have practised resection successfully in these 
accidents, and have added their testimony in favor of this mode of 
procedure. 

§ 2. Dislocations of the First Phalanx of the Thumb forwards. 

Up to the present moment, I have met with but two examples of 
this dislocation, while, as has been already stated, the backward dis- 
location has been seen by me seven times. 

Horace Kneeland, of Eochester, N. Y., set. 24, dislocated the first 
phalanx of the right thumb forwards, by striking a man with his 
clenched fist ; the force of the blow being received upon the back of 
the second joint of the thumb. The dislocation had existed three 
dajs when he called upon me, and in the meanwhile several attempts 
had been made to reduce the bone by simple extension. The first 
phalanx was in front of the metacarpal bone, and in the same plane ; 
but the last phalanx was slightly inclined backwards. The hand was 
already swollen and quite painful. 

Seizing the dislocated thumb in the palm of my right hand, with 
my fingers resting upon the back of the patient's hand, I forced the 
two phalanges into flexion by firm and steady pressure continued for 
a few seconds, when suddenly the bones resumed their places, and all 
deformity disappeared. 

Intense inflammation resulted, followed, after a few days, by suppu- 
ration under the palmar fascia ; and in the end the thumb was almost 
completely anchylosed. 2 

On the 24th of April, 1855, J. M. Booth, of Buffalo, set. 19, called 
at my office, having a dislocation forwards of the first phalanx, occa- 
sioned, about half an hour before, by being thrown from a horse. The 
last two phalanges were neither flexed nor extended, but straight, and 
parallel with the metacarpal bone. 

By the same manoeuvre adopted in the preceding case, but with 
only very moderate force, the dislocation was promptly reduced. 

The usual causes of this accident are, falls or blows upon the thumb 
while it is flexed ; and the symptoms which characterize it are, in 
general, such as we have seen in the two examples which have just 
been given. The" metacarpal bone projects posteriorly, and the first 
phalanx produces a corresponding projection toward the palm ; the 
two phalanges are extended upon each other, and parallel with the 
metacarpal bones. Nelaton saw a case in which the first phalanx was 
flexed about 45° ; and in several examples it has been observed to 
be slightly rotated inwards. 

1 Norris, Amer. Journ. Med. Sci., vol. xxxi. p. 16. 

2 Trans. N. Y. State Med. Soc, 1855, p. 73. 



630 OF FIEST PHALANGES OF THUMB AND FIXGERS. 

In the few examples of this accident which have been reported, the 
reduction was easily accomplished ; or, at least, we may say that the 
difficulties in the way of reduction were not so great as they are 
usually found to be in dislocations backwards. Malgaigne has been 
able to collect but four undoubted examples, all of which were re- 
duced ; Lenoir was able to effect the reduction by moderate measures, 
after the bone had been dislocated thirty-eight days. Ward succeeded 
by simple extension. 1 

Lombard, after the trial of other plans, finally succeeded by revers- 
ing the phalanx. Employing, as we have before termed it, "dorsal 
flexion," with extension and lateral motion ; but in all, or nearly all 
the other examples, the reduction has been effected by flexing the 
thumb forcibly toward the palm ; the reverse of the method which 
we have seen preferred, especially by American surgeons, in disloca- 
tions backwards. My own experience also authorizes me to recom- 
mend this plan. 

§ 3. Dislocations of the First Phalanx of the Fingers. 

The index and little fingers, owing to their exposed situations, are 
most liable to these dislocations. I have met with two examples of 
traumatic dislocations of these joints, one of which was a forward, and 
the other a backward luxation, and both had occurred in the index 
finger. 

James Kesbitt, of Buffalo, set. 11, dislocated the index finger of the 
right hand, backwards, by a fall down a flight of stairs. On the same 
day, Feb. 11, 1851, he called upon me, and I found the finger neither 
flexed nor extended, but straight and immovable. The projections 
occasioned by the ends of the two bones were very marked, and such 
as to render an error in the diagnosis impossible. Eeduction was 
accomplished with great ease, by reversing the finger and employing 
moderate extension, while at the same time the proximal extremity of 
the first phalanx was pushed toward the distal end of the metacarpal 

Fig. 257. 




Backward dislocation of first phalanx. Reduction by extension. 

bone. In short, the process was the same as that which we have 
recommended in dislocations of the thumb backwards. 

In the example of dislocation forwards, occasioned by a blow from 

1 Ward, New York Med. Times, Sept. 8, 1S60. 



PHALANGES OP THE THUMB AND FINGEKS. 631 

a hard ball, received upon the end of the finger, the first phalanx was 
in a position of extreme extension, and the second moderately flexed. 
Eeduction was effected with great ease by extension in a straight line. 
But if the surgeon were to experience difficulty in the reduction, it 
would no doubt be advisable to resort to the method of extreme 
flexion. 

In one instance, I have seen nearly all the fingers of the left hand, 
and the thumb of the right dislocated backwards, by the contraction 
of the cicatrix after a severe burn. 



CHAPTEE XY. 

DISLOCATIONS OF THE SECOND AND THIRD PHA- 
LANGES OF THE THUMB AND FINGERS. 

Notwithstanding slight differences in the form of the articulations 
between the thumb and fingers, and in the size and situation of the 
bones which compose the phalanges of the fingers, we are disposed, 
contrary to the practice of some other writers upon this subject, to 
consider all the dislocations to which these several joints are liable, 
under one section. Nor, indeed, after the attention which we have 
given to the dislocations at the metacarpo-phalangeal articulations, do 
we find much to add in relation to these accidents ; since in almost 
every point of view in which they may be considered, they have so 
much in common. 

The last phalanx of the thumb is, of all the phalanges, most liable 
to dislocation, and this generally takes place backwards. Very 
frequently, also, it is accompanied with such a laceration as to render 
it compound. The dislocated phalanx is usually reversed in the 
backward dislocation, and straight, or nearly so, in the forward dislo- 
cation. 

In most cases reduction may be accomplished easily by forced dorsal 
flexion, in the case of the backward luxation, and by forced palmar 
flexion, in the case of the forward dislocation. 

In the winter of 1848, a young man was brought into my clinic, 
who had met with a forward subluxation of this phalanx about one 
month before. He had fallen upon the end of his thumb, and as the 
accident was followed by a good deal of inflammation and swelling, 
he did not notice the displacement until some time afterwards. The 
proximal end of the last phalanx projected two or three lines toward 
the palm; the finger was straight, and this joint anchylosed. I did 
not think the chance of restoring and maintaining the bone in position 
sufficient to warrant any interference, and he was dismissed with an 
assurance that after a few months it would occasion him no great 
inconvenience. 

On the 2d of March, 1851, Thomas Burton, aged about twenty-two 



632 



PHALANGES OF THE THUMB AND FINGERS. 



years, by a fall dislocated the second phalanx of the middle finger of 
the right hand, backwards. The force of the concussion was received 
upon the extremity of the finger. Nine hours after the accident I 
found the bones unreduced; the finger nearly straight, or with only 
slight flexion of the second phalanx upon the first; the third phalanx 
forcibly straightened upon the second; all the joints rigid; finger very 
painful and somewhat swollen. 

By moderate extension alone, applied for a few seconds, the reduc- 
tion was accomplished. 

Fig. 258. 




Dislocation of the second phalanx backwards. 

James Cooper, set. 23, came to me on Sunday morning the 14th of 
Dec. 1851, to obtain counsel in relation to his finger which had been 
dislocated the day before, but which he had himself reduced by simple 
extension made in a straight line. His own account of it was, that he 
fell upon a slippery side-walk, striking upon the end of his ring finger 
in such a way that it seemed to double under him. On examination, 
he found the second bone dislocated inwards, or to the ulnar side, com- 
pletely, the end of the first phalanx forming a broad projection upon 
the opposite side; the last two phalanges fell over toward the middle 
finger, but they were neither flexed nor extended. Seizing upon the 
end of the finger with his right hand and palling forcibly, he promptly 
reduced the dislocation himself. 

The bones were now completely in place, but the joints were swollen, 
tender, and quite stiff. 

In Sept. 1851, by the politeness of Dr. Briggs, the attending sur- 
geon, I was permitted to see in the hospital of the New York State 
Prison, at Auburn, a forward dislocation of the second phalanx of the 

Fig. 259. 




Dislocation of the second phalanx forwards. 



little finger of the left hand, unreduced. This man was at the date of 
my examination forty-one years old, and the dislocation had existed 
eighteen years; having been occasioned by a fall. A surgeon in 
Greene Co., N. Y., had attempted to reduce it soon after the dislocation 



PHALANGES OF THE THUMB AND FINGEKS. 633 

occurred, but bad failed. Tbe joint was nearly anchylosed, yet tbe 
finger was quite as useful for all ordinary purposes as before. 

Dislocation of tbe last pbalanx is frequently occasioned in tbe 
game of base ball, by tbe ball being received upon tbe extremity of 
tbe finger. 

A young man wbo was studying medicine, and a private pupil of 
mine, in attempting to catcb a very bard ball, received it upon tbe 
extremity of tbe middle finger of tbe left band, dislocating tbe last 
pbalanx forwards. Twenty minutes after tbe accident, I found tbe 
distal extremity of tbe second pbalanx projecting backwards tbrougb 
tbe skin, tbe tendon of tbe extensor muscle being torn completely off 
from its point of attacbment to tbe last pbalanx. Tbe last pbalanx 
was in a position of sligbt dorsal flexion, or extreme extension. 

Seizing upon tbe extremity of tbe finger, I attempted to reduce tbe 
dislocation by direct traction, aided by pressure upon tbe exposed end 
of the second pbalanx, but I was unable to succeed until I brought 
tbe last phalanx into a position of palmar flexion. 

A slight disposition to reluxation was manifested, and a gutta- 
percha splint was therefore applied; and to prevent inflammation, 
the young man was directed to keep it moistened with cool water 
lotions. Only a moderate amount of inflammation followed, and in a 
few weeks the cure was complete. 

Such accidents, attended with laceration of the integuments, fre- 
quently demand amputation, or at least resection of the projecting 
bone, but we think Mr. Miller is scarcely right when he says that 
compound dislocations of tbe fingers almost always are of such severity 
as to demand amputation. I have myself met with two other cases 
which were reduced, and did well. 

In one case of simple dislocation of the last pbalanx of the thumb 
backwards I have been obliged to resort to section of the lateral liga- 
ments before accomplishing the reduction. This was in the person of 
a woman admitted to Bellevue Hospital in February, 1864. The acci- 
dent had happened seven days before, by falling and striking upon 
the end of the thumb. The position of the last phalanx was extended, 
that is, in a line with the axis of the first phalanx. She said, how- 
ever, that it was at first ''bent straight back," but that a man took hold 
of it and pulled it out. Having placed her under the influence of 
ether I attempted reduction by forced backward flexion, but failed. I 
then cut the lateral ligaments by subcutaneous incision and the reduc- 
tion was accomplished with great ease. 



41 



634 DISLOCATIONS OF THE THIGH, 



CHAPTEE XVI. 

DISLOCATIONS OF THE THIGH ( C OXO-FEM R AL). 

The femur is especially liable to dislocation in four directions, 
namely, upwards and backwards upon the dorsum ilii, upwards and 
backwards into the ischiatic notch, downwards and forwards into the 
foramen thyroideum, and upwards and forwards upon the pubes. 

Dislocations are occasionally met with which cannot be arranged 
properly under either of these divisions ; indeed, it is scarcely neces- 
sary to say that the head of the bone may be thrown in almost every 
direction from its socket, upwards, downwards, inwards, and outwards, 
or in either of the diagonals between these lines ; and that while in a 
vast majority of cases it will assume one of the positions first named, 
it may in a few exceptional examples fall short of, or much exceed the 
limits assigned in this division. Thus, we shall have occasion here- 
after to mention examples of dislocation directly upwards, in which 
the head of the bone will be found resting upon the fossa between the 
upper margin of the acetabulum and the anterior inferior spinous pro- 
cess of the ilium, or still higher between the anterior superior and the 
anterior inferior spinous processes, or a little to the one side or to the 
other of these points. Examples will be shown of dislocations directly 
downwards, in which the head of the femur will rest upon the notch 
between the lower margin of the acetabulum and the tuber ischii, or 
still lower, and actually below the tuberosity, or downwards and back- 
wards below the spine of the ischium, into the lower or lesser sacro- 
sciatic notch. The head may be thrust across the foramen thyroideum, 
and be only arrested in the perineum upon the ramus, or even beyond 
the ramus of the ischium and pubes.; it may lodge upon the anterior 
surface of the body of the pubes, as well as upon its superior edge ; 
and finally, it may rest against the posterior margin of the acetabulum 
instead of rising upon the dorsum, or it may only mount upon its 
margin, in either of the directions named. 

In regard to frequency, the four principal dislocations occur in the 
order in which we have mentioned them ; thus, of 104 dislocations of 
the hip which I have taken the pains to collate, excluding the anoma- 
lous or extraordinary dislocations, and which my intelligent pupil, Mr. 
Frank Hodge, has carefully analyzed, 55 were upon the dorsum ilii, 
28 into the great ischiatic notch, 13 upon the foramen thyroideum, and 
8 upon the pubes. Chelius and Samuel Cooper have, however, re- 
versed the order of the last two varieties, arranging dislocations upon 
the pubes, in the order of frequency, before dislocations into the fora- 
men thyroideum. 



DISLOCATIONS OF THE THIGH. 635 

Coxofemoral dislocations may occur at any period of life; one 
example is mentioned, in the Gazette Medicale, of a recent dislocation 
upon the dorsum ilii, in a child eighteen months old. 1 Mr. Kirby has 
reported in the Dublin Medical Press for October 26, 1842, a case of 
recent dislocation in the same direction, in a child of three years, 2 and 
Dr. Buchanan has seen another, at the same age, in a little girl; the 
dislocation being into the ischiatic notch. 3 Mr. Image communicated 
to the Suffolk branch of the Provincial Medical and Surgical Associa- 
tion the case of a boy, three and a half years old, with a dislocation 
upon the dorsum ilii. It had existed twelve days when he was ad- 
mitted to the Suffolk Hospital in May, 1847. Mr. Image, in reporting 
this case to the Society, remarked that he had been induced to lay it 
before them "in consequence of a charge having been urged against a 
neighboring surgeon, of pretending to reduce a dislocation of the femur 
on the dorsum ilii, in a child only four years old, that child being a 
pauper, and chargeable to the parish. It was agreed and proved by 
authorities . that no such case was recorded, and therefore had not 
occurred, and that seven years old was the earliest period at which this 
accident had taken place." 4 

J. M. Litten, of Austin, Texas, reports a case of dislocation upon 
the dorsum ilii in a girl four years old, which he reduced by manipu- 
lation. 5 In the Jan. No. for 1847 of the American Journal of Medical 
Sciences, is reported a forward dislocation in a boy aged 5 years, and 
a dislocation into the ischiatic notch in a girl of the same age. 

Dr. J. C. Warren, of Boston, met with an incomplete dislocation 
toward the foramen thyroideum, in a child six years old, which having 
been displaced eight or ten weeks, he was unable to reduce. 6 Sir 
Astley Cooper mentions a case in a girl seven years old. 7 I have 
myself met with two dislocations upon the dorsum ilii, which occurred 
at ten years, and one into the foramen thyroideum. 8 Korris reports a 
case at eleven years, 9 and Gibson at twelve. 10 On the other hand, 
Gauthier has seen a dislocation of the hip in a woman eighty-six years 
of age. 11 The large majority, however, occur between the fifteenth 
and forty-fifth years of life. From an analysis of eighty-four cases, 
we have obtained the following results : — 

Under 15 years 15 cases 

15 to 30 " 32 " 

30 to 45 " 29 " 

45 to 60 " . . . . . 7 " 

60 to 85 " 1 case 



1 New York Journ. Med., Nov. 1850, p. 416. 

2 Amer. Journ. Med. Sci., vol. xxxi. p. 207, Jan. 1843. 

3 London Med.-Chir. Rev., Dec. 1828, p. 251. 

4 New York Journ. Med., Sept. 1848, p. 281. 

5 Ibid., March, 1852, p. 259. 

6 Boston Med. and Surg. Journ., vol. xxiv. p. 220. 

7 A. Cooper, on Disloc, Amer. ed., p. 83, Case 27. 

8 Buf. Med. Journ., vol. viii. p. 6. Trans. New York State Med. Soc, 1855. My 
Report on Disloc. 

9 Amer. Journ. Med. Sci., Feb. 1839, p. 296. I0 Gibson's Surg., vol. i. p. 3S9. 
11 Gauthier, Malgaigne, op. cit., p. 805. 



686 DISLOCATIONS OF THE THIGH. 

The youngest being eighteen months old, the oldest sixty-two years, 
and the average thirty-four years. 

They are much more frequent in men than in women ; owing, pro- 
bably, to the greater exposure of the former to the accidents from 
which these dislocations usually result, and possibly, also, in some 
measure, to certain peculiarities in the form and structure of the neck 
of the femur in the male. Of one hundred and fifteen cases collected 
by me, one hundred and four were in males and eleven in females. 
Dr. J. K. Eodgers, of jSTew York, mentioned, however, at a meeting of 
the New York Kappa Lambda Society, that he had seen and reduced 
four dislocations of the femur upon the dorsum ilii in females, and 
that a fifth case had recently come to his knowledge in the New York 
City Hospital. 1 

Gibson mentions an example of dislocation of both thighs at the 
same moment. 2 

§ 1. Dislocations Upwards and Backwards on the Dorsum Ilii. 

Syn. — "Upwards on the dorsum ilii ;" Sir A. Cooper, Miller, Pirrie. " Upwards and 
outward ;" Boyer, Dupuytren. " Upwards and backwards upon the back of the hip 
bone ;" Chelius. "Iliac ;" Grerdy, Vidal (de Cassis), Malgaigne. 

Causes. — Generally they are occasioned by some violence which 
forces the thigh into a state of extreme adduction, or of adduction 
united with rotation inwards ; and especially when at the same mo- 
ment the head of the femur is driven upwards and backwards. Thus, 
a dislocation upon the dorsum may result from a fall from a height, 
when the force of the concussion is received upon the outside of the 
knee ; the thigh being thus converted into a lever of the first kind, 
whose long arm is outside of the margin of the acetabulum ; or the 
dislocation may be occasioned by a fall upon the foot or kuee, while 
the limb is adducted, by which the head of the femur will be at the 
same moment driven upwards and outwards from its socket. The 
accident is equally liable to result from the fall of a heavy weight, 
such as a mass of earth, upon the back of the pelvis when the body 
is much bent forwards. 

The following case presents an extraordinary example of this form 
of dislocation, produced by a force acting upon the thigh as a lever of 
the first kind. 

B., of Rochester, 1ST. Y., aet. 10, fell, in Feb. 1841, from the top of the 
high bank just below the Genesee Falls, at Rochester, a distance of 
about one hundred feet. Before he reached the bottom of the preci- 
pice, he struck upon an oblique plane of ice, from which he slid gradu- 
ally down upon the surface of the river, which was then completely 
frozen over. He did not lose his consciousness in the descent, nor 
after his arrest upon the river, but began immediately to call for as- 
sistance. He remembers very well that when he struck the glacier, the 
concussion was received upon the right side of the right knee, and a 

1 J. K. Rodgers, New York Journ. Med., July, 1839, vol. i. First ser. p. 220. 
'■ Gibson's Surg., vol. i. p. 385. Sixth ed. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 637 



Fig. 260. 



mark of contusion at this point confirmed his statement. Dr. Ellwood*, 
of Kochester, assisted by myself, reduced the dislocation within one 
hour after its occurrence. We employed pulleys, but the reduction 
was accomplished easily in about two minutes, and without the appli- 
cation of much force ; the bone resuming its place with an audible 
snap. His recovery was rapid and complete. 1 

Pathological Anatomy. — The capsule is lacerated more or less ex- 
tensively, but especially in its posterior half ; the round ligament is 
ruptured ; some of the small external 
rotator muscles are generally stretched 
or torn completely asunder, the glutaens 
maximus,medius, and minimus are pushed 
upwards and folded upon each other, the 
head of the femur resting upon or within 
the fibres of the deeper muscles ; the tri- 
ceps adductor is put upon the stretch. 

Surgeons have not been agreed as to 
the cause of the great difficulty which 
has usually been experienced in the re- 
duction of this and of all other forms of 
coxo-femoral dislocations. While some 
have ascribed it alone to the resistance of 
the muscles, others have with equal con- 
fidence ascribed the opposition to an en- 
tanglement of the head and neck of the 
bone in the rent capsule ; and still others 
believe that the impediment ought to be 
looked for sometimes in the muscles and 
sometimes in the capsule, or in both at 
the same moment. 

Sir Astley Cooper thought that the cap- 
sular ligament was generally too much torn to offer any impediment 
to reduction, and he refers to some dissections in confirmation of this 
opinion. Nathan Smith affirmed that the chief obstacle to reduction 
by extension was to be found in the resistance offered by the gluteii 
muscles, which, although at first relaxed, would soon become tense 
under the stimulus of the extension, and which, in order that the bone 
might resume its position, must actually be stretched considerably 
beyond their normal length. W. W. Eeid declares that the sole 
resistance is at first in the abductors and rotators, but that finally the 
psoas magnus, iliacus internus, and triceps adductor become tense 
where the pulleys are employed. 

Dr. Fenner, of New Orleans, gives the particulars of a dissection of 
the hip of a man admitted into the Charity Hospital, who died from 
injuries received by the bursting of a steamboat boiler. His condi- 
tion being considered hopeless, no attempt was made to reduce the 
dislocation. The limb was shortened one inch and a half, and the toes 
turned inwards. Extensive ecchymosis existed. On raising the glu- 




Dislocation upon the dorsum ilii. 



1 Trans. New York State Med. Soc, 1855, p. 76. My report on Dislocations. 



638 DISLOCATIONS OF THE THIGH. 

tseus maximus and medius, the naked head of the femur was found 
lying on the dorsum ilii with the ligamentum teres hanging to it, but 
partially torn off. Portions of the obturator externus, pyriformis, and 
gemelli were ruptured and lacerated. The capsule was torn through 
one-half of its extent. 

Dr. Fenner now proceeded to cut away the muscles, and when all 
the external muscles about the joint had been removed the thigh could 
not be brought down ; the iliacus interims and psoas magnus were 
then severed, which permitted it to descend a little, but the head could 
not be replaced ; the triceps adductor was then divided without effect. 
The ilio-femoral ligament was found tensely stretched. All the mus- 
cles between the pelvis and the thigh were then severed, and still it 
was impossible to reduce the dislocation ; the head of the femur could 
not be forced back through the rent in the capsule from which it had 
escaped ; and it was not until the opening was enlarged from one-half 
to three-quarters of an inch, that the reduction was accomplished. 

Dr. Fenner infers that the capsule possesses sufficient elasticity to 
allow the small head of the femur to pass out through a lacerated 
opening, which might at once contract, so as to offer considerable re- 
sistance to its return, and that occasionally this is the true explanation 
of the difficulty in reduction. 1 Dr. Gunn, of Ann Arbor, Michigan, 
after repeated experiments made upon the dead body, concludes that 
the -muscles offer no impediment whatever to the reduction, and that 
the "untorn portion of the capsular ligament, by binding down the 
head of the dislocated bone, prevents its ready return over the edge 
of the acetabulum to its place in the socket." 2 Dr. Moore, of Kochester, 
who has often repeated the same experiments upon the cadaver, de- 
clares, also, that in attempting to reduce the femur by extension alone 
he has constantly observed that the untorn portion of the capsule 
offered the main resistance, and that reduction could not be accom- 
plished until this was more completely broken up ; 3 while Markoe, of 
New York, attributes the resistance to both the muscles and the cap- 
sule, but chiefly to the action of the former, especially the rotators. 4 

The conclusion to which we ought to arrive seems to be that in 
some cases, the capsule being completely, or almost completely torn 
away, the muscles offer the only resistance ; and that according to the 
exact position of the limb or degree of displacement, one or another 
set of muscular fibres will oppose the reduction ; and in other cases, 
the muscles being paralyzed by the shock, or by anaesthetics, the par- 
tially torn capsule, into which the head of the bone is received as in 
a buttonhole, prevents its free return into the socket. 

Symptoms. — Sir Astley Cooper affirmed that the limb was some- 
times found shortened in this dislocation to the extent of three inches. 
Liston, B. Cooper, Gibson, and others repeat the affirmation. Chelius 
places the extreme of shortening at two and a half inches, Miller at 

1 New York Journ. Med., Sept. 1848, p. 268; from New Orleans Med. and Surg. 
Journ., July, 1848. 

2 Ibid., Nov. 1853, p. 423, et seq. » ibid., July, 1855, p. 69. 
* Ibid., Jan. 1855. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 639 



two inches, while Malgaigne declares that he has never seen the limb 
shortened more than half an inch, and that in some cases it is not 
shortened at all, and the very opposite opinions entertained by other 
surgeons, he attributes to errors in the measurement. I am certain, 
however, that Malgaigne has fallen into some error, and that, while 
the average shortening is about one 

inch or one inch and a half, it does Fi g- 261 - 

occasionally reach three inches. 

The thigh is rotated inwards, ad- 
ducted and slightly flexed upon the 
pelvis. The great toe of the dis- 
located limb, when the patient 
stands erect (and in this position 
the examination ought, if possible, 
to be made), rests upon the instep 
of the foot of the sound limb, and 
the knee touches the opposite thigh 
near the upper margin of the pa- 
tella. It must not be supposed, 
however, that the position of the 
limb is in all cases precisely such 
as we have described. Indeed the 
degree of rotation, adduction, flex- 
ion, &c, will vary according as the 
head of the femur is more or less 
displaced, the capsule more or less 
torn, or as it may be torn in its 
upper or lower margins, as the 
muscles may be actually rent asun- 
der, or only put upon the stretch, 
and perhaps also according to 
the amount of injury and conse- 
quent relaxation which they may 
have sustained from the shock. 
The thigh can be easily flexed ; 
adduction is more difficult, but ab- 
duction is almost impossible, except 
to a very limited extent : the body 
of the patient is a little bent for- 
wards-, ; he roundness of the hip is lost in consequence of the relaxa- 
tion of the gluteii muscles; the trochanter major is depressed, and 
approaches the anterior superior spinous process of the ilium, and 
if the patient is not fat, and swelling has not already taken place, the 
head of the femur may be felt in its new position rotating under the 
hand when the limb is turned inwards or outwards, but especially 
may it be felt when, by flexing or extending the limb, the head is 
made to move downwards and upwards, upon the dorsum ilii. 

As we have already said, this examination ought to be made, if 
possible, in the erect posture ; after which, it will be well to place the 




Dislocation upon the dorsum ilii. 



640 DISLOCATIONS OF THE THIGH. 

patient alternately upon his back, upon his sound side, and upon his 
belly, until the diagnosis is rendered complete. 

The differential diagnosis between dislocation upon the dorsum ilii 
and a fracture of the neck of the femur may be briefly stated as follows. 

In fracture, we may expect to find crepitus ; the limb is in most cases 
mobile; the toes are generally turned out ; the limb is shortened mode- 
rately or not at all ; the patient is sometimes able to walk for a short 
distance; fractures of the neck of the femur generally occur in ad- 
vanced life. 

In dislocation, crepitus is not often present, and only when a frac- 
ture coexists; the limb is immobile, or nearly so; the toes are turned 
in; the limb is shortened more; the patient is unable to bear the 
weight of his body upon his foot for one moment. Skey, however, says 
he has seen a patient with a recent dislocation, who walked one-quar- 
ter of a mile, to the hospital. I do not think any other similar case is 
upon record. Dislocations of the femur generally occur in middle life. 

I have been frequently told by persons who have called upon me 
with children suffering under hip-disease, that they had been informed 
the hip was out, and they expected me to reduce it. In two or three 
instances they have blamed their surgeons very much, because they 
had not detected the accident at the time of its occurrence. Norris, of 
Philadelphia, mentions an extraordinary example of this kind, as 
having been presented at the Pennsylvania Hospital, and which ought 
to serve as a sufficient warning to prevent similar mistakes in future. 
A lad, twelve years old, was brought to the hospital from a neighbor- 
ing State, who a short time previous had been suddenly attacked with 
lameness in his right limb, and which, by his friends, was attributed 
to some injury received in play. Two physicians, who had been called 
to see the boy, pronounced him to be laboring under dislocation of 
the hip, and had made two strong efforts with the pulleys, to reduce it; 
but after causing great suffering they gave up all hopes of ever re- 
placing the bone, and sent him to Philadelphia. The symptoms were 
plainly those of hip-joint disease in its early stage. The attitude was 
that assumed by those laboring under this affection ; the leg seemed 
lengthened, but a careful measurement showed that it was of the same 
length with the other ; the buttock was flattened and the motions of 
the joint tolerably free but painful. 1 

If the supposed dislocation occurs in a child, or in a person under 
ten years of age, we ought to take especial pains to ascertain that it is 
not a separation of the epiphysis, of which accident we have men- 
tioned some examples when speaking of fractures of the neck of the 
femur. 

Prognosis. — Boyer says the limb remains always weaker than the 
other, the round ligament never uniting completely; and that inflam- 
mation of the cartilages and synovial glands may ensue, ending in 
caries of the joint. Such results have, indeed, been occasionally met 
with, nor are examples wanting in which more rapid inflammation, 
resulting in the formation of acute abscesses, has followed, but these 

i Norris, Amer. Journ. Med. Sci., vol. xxv. p. 280. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 641 

are only rare accidents. In the large majority of cases the patients 
recover speedily, and in the course of a few weeks, or months at most, 
the limb seems to be as sound and as useful as before. 

Examples of non-reduction, however, from an error of diagnosis, or 
what is more pertinent to our present purpose, from a failure to 
accomplish the reduction where the attempt has been made, are 
numerous. Fortunately, Mr. Chelius, the author of a most excellent 
"System of Surgery," to which we have already had frequent occasion 
to refer, has sufficient reputation, the world over, to enable him to 
bear a portion of these failures, without injury to himself or to the 
profession which he so eminently adorns. We shall therefore make 
no apology for reporting the following unsuccessful attempt to reduce 
a dislocation of the hip in which Mr. Chelius himself was the operator. 

On the 11th of June, 1851, John Mauren, a German, set. 19, called 
at my office and related as follows: "When ten years old, I fell from 
a tree, a height of six feet, and dislocated my left hip. I was then 
living twelve miles from Heidelberg, and I was immediately taken 
there, but I did not see Mr. Chelius until the next morning. He took 
me to the University, and, before the medical class, attempted to reduce 
it, but he could not. During several weeks following, he tried six 
times, using pulleys, &c, but he could never succeed." 

On examination I found the limb shortened two inches, the head of 
the femur lying upon the dorsum ilii ; the knee was turned in, but 
the toes were inclined a little outwards. He was able to walk rapidly, 
of course with a manifest halt, yet without pain and discomfort. 

Treatment. — Kegarding dislocations of the femur upon the dorsum 
illi as the type of all the coxo-femoral dislocations, the remarks which 
we shall make under this section may be considered applicable, with 
only certain qualifications^ to all the others. 

We shall arrrange the various methods of reduction which have 
been employed by surgeons under two principal heads, namely, mani- 
pulation and extension. It is not possible, however, to classify rigidly 
the different procedures, so as to bring them under these two simple 
divisions without some violence; since neither manipulation nor ex- 
tension has usually been employed alone, but almost always some 
degree of extension has been recommended in connection with the 
manipulation; if not in the first instance, at least in the event of the 
failure of manipulation alone ; while on the other hand, extension is 
seldom if ever practised without manipulation. We intend then to 
imply by these designations respectively, that either manipulation or 
extension has constituted the prevailing feature in the treatment. 

Eeduction by manipulation dates from the earliest records of our 
science. Says Hippocrates : ■' In some the thigh is reduced with no 
preparation, with slight extension directed by the hands, and with 
slight movement; and in some the reduction is effected by bending 
the limb at the joint, and making rotation." 1 

Eichard Wiseman, who wrote in 1676, speaks as follows: "If the 
thigh-bone be luxated inwards, and the patient young and of a tender 

1 Works of Hippocrates, Syd. ed., vol. ii. p. 643. 



64:2 DISLOCATIONS OF THE THIGH. 

constitution, it may be reduced by the hand of the chirurgeon, viz : he 
must lay one hand on the thigh, and the other on the patient's leg, and 
having somewhat extended it toward the sound leg, he must suddenly 
force the knee up toward the belly, and press back the head of the 
femur into its acetabulum, and it will snap in. For there is no need 
of so great extension in this kind of luxation; for the most consider- 
able muscles being upon the stretch, the bowing of the knee as afore- 
said reduceth it; yet in rough bodies it may require stronger exten- 
sion." 1 

Eichard Boulton repeated, in 1713, almost the same instructions, 
affirming that this plan was applicable especially to dislocations in- 
wards, in the case of " young and tender children." 2 

In 1742 Daniel Turner declared that he had reduced three disloca- 
tions of the hip, one of which was a backward dislocation, by a 
method combining extension with manipulation, but alone " by the 
strength of the arm or without any other instrument." Extension 
and counter-extension being made by assistants, and " as soon as the 
surgeon perceives the bone moving out," says Turner, "let him take 
his opportunity, giving orders to the extenders below suddenly to lift 
up the patient's thigh toward his belly, pressing with his hands, 
either to the right or left, as the situation of the same requires, and 
therewith force back its head toward the acetabulum, whereunto it 
will, flipping over the tip of the cartilage, snap sometimes with a loud 
noise." 3 

Thomas Anderson, surgeon of Leith, in Scotland, was called, in 
Sept. 1772, to see a man who had dislocated his left femur into the 
foramen thyroideum. When he arrived four other surgeons were 
present, and prepared to use the pulleys, which they did in his pre- 
ence several times, but to no purpose. After examining the limb 
carefully, " I was convinced," says Mr. Anderson, "that attempting 
the reduction in the common method, with the thigh extended, was 
improper, as the muscles were all put on the stretch, the action of 
which is, perhaps, sufficient to overbalance any extension we can ap- 
ply. But by bringing the thigh to near a right angle with the trunk, 
by which the muscles would be greatly relaxed, I imagined that the 
reduction might more readily take place, and with much less exten- 
sion. 

" When I made this examination, he was lying on a table on his 
back. I raised the thigh to about a right angle with the trunk, and, 
with my right hand at the ham, laid hold of the thigh, and made what 
extension I could. From this trial I found I could dislodge the head 
of the bone. At the same time that I did this, with my left hand at 
the head and inside of the thigh, I pressed it toward the acetabulum, 
while my right gave the femur a little circular turn, so as to bring 
the rotula inwards to its natural situation ; and on the second attempt, 

1 Eight Chirurgical Treatises. By Richard Wiseman, Serjeant-Chirurgeon to King 
Charles II. London, 1676. Book vii. chap. viii. 

2 A System of Rational and Practical Surgery. By Richard Bovlton. London, 1713, 
p. 346. 

3 The Art of Surgery, by Daniel Turner, London, 1742, vol. ii. p. 339. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 643 

it went in with a snap observable to the gentlemen standing^ around, 
but more so to the poor man, who instantly cried out he was well and 
free from pain. His knees could then be brought together ; the legs 
were of the same length, and the foot in its natural situation. The 
knees were kept together for some time, with a roller, to confine the 
motion of the thigh ; and in three weeks he was at his work, without 
the least stiffness in the joint." 

Subsequently Mr. Anderson reduced by a similar method a dislo- 
cation upon the dorsum ilii in a child eight years old, and which had 
been out nineteen days. 1 

Says Pouteau, in a memoir on dislocations of the thigh upwards 
and outwards : " We observe then, first, that the thigh ought to be 
flexed to a right angle with the body during the extension and coun- 
ter-extension ; second, that we ought to rotate the thigh from within 
outwards, when the extension appears to be sufficient ; third, that this 
position puts into relaxation, as much as possible, the triceps and 
gluteal muscles which oppose the chief resistance to the extension, 
thus saving the patient from excessive pain ; fourth, that the flexion 
of the thigh places the head of the bone in the best position for a re- 
turn to the cotyloid cavity during extension ; fifth, that feeble exten- 
sion suffices for the reduction, because all of the muscles of the thigh 
are relaxed." 2 

On the 7th of Jan. 1811, Dr. Philip Syng Physick, of Philadelphia, 
reduced an outward dislocation of the hip, after extension had failed, 
by flexing the thigh to a right angle with the body, and then giving 
to the limb " an outward circular sweep." 3 

So early as 1815, and perhaps much earlier, Nathan Smith, Prof, of 
Surgery in the New Haven Medical College, taught that the only cor- 
rect mode of reducing a dislocation upon the ilium was to flex the 
leg upon the thigh, the thigh upon the pelvis, and then to carry the 
limb diagonally to the opposite side, from whence it was to be brought 
outwards and downwards ; 4 and in 1824, Dr. Smith, being under oath, 
affirmed as follows: "I do not think that the mechanical powers, such 
as the wheel and axle, or the pulleys, are necessary to reduce a dislo- 
cated hip, or any other dislocation." He further adds that he once reduced 
a dislocation upon the dorsum ilii after he had pulled in every direc- 
tion but the right, " by carrying the knee towards the patient's face." 5 
Subsequently the son of Dr. Smith, Nathan K. Smith, the present dis- 
tinguished teacher of surgery in the medical college at Baltimore, 
gave a more full account of his father's method, illustrating his views 
of the pathology of these dislocations, and the mechanism of their 
reduction by several drawings. It must be noticed, however, that 
Dr. Nathan Smith left no written explanation of his views and prac- 

1 Anderson. Medical Commentaries, Edinburgh, 1776, vol. ii. pp. 261-4. 

2 Vidal (de Cassis) ; from (Euvres posthumes de Pouteau, Paris, 1783. 

3 Physick, Dorsey's Surg., 1813, vi. p. 242. Mem. of Nathan Smith, 1831, p. 172. 
Phelps' paper, in Trans. New York State Med. Soc, 1856, p. 169. 

* Trans. N. H. St. Med. Soc, 1854, p. 55. 

5 Report of the Trial of an Action for Malpractice. Lowell v. Faxon and Hawks, 
Mauhias, Maine, 1824; also Buff. Med. Journ., vol. xiii. p. 515. 



614: DISLOCATIONS OF THE THIGH. 

tice, except that which is to be found in the affidavit already quoted, 
and that the account published by his son is from memory, and it is 
given as follows : " The patient being prepared for the operation by 
whatever means may be deemed necessary, may be placed in an atti- 
tude convenient for the operation, with the body securely fixed, by 
placing him in the horizontal posture, on a narrow table covered with 
blankets, and on the sound side. To the table his body should be 
firmly fixed, and this can be conveniently done by folding a sheet 
several times, lengthways — then applying the middle of the broad 
band thus made to the inner and upper part of the sound thigh — 
carrying its extremities under the table, crossing them beneath it, and 
then carrying them obliquely up and crossing them firmly over the 
trunk, above the injured hip. The ends may then be secured beneath 
the table. To support the trunk the more firmly, a pillow may be 
placed on each side of it upon the table, and be included in the band- 
age. Should the operator design to employ any degree of extension, 
a counter-extending band may be placed in the perineum, and carried 
up to the extremity of the table, be fixed to some more firm body, or 
held by the hands of assistants. 

" The operator now standing on the side to which the patient's back 
presents, grasps the knee of the dislocated member with his right 
hand (if the left femur be dislocated — vice versa, if the right), and the 
ankle with the left. The first effort which he makes is to flex the leg 
upon the thigh, in order to make the leg a lever with which he may 
operate on the thigh-bone. The next movement is a gentle rotation 
of the thigh outwards, by inclining the foot toward the ground, and 
rotating the knee outwards. Next the thigh is to be slightly abducted 
by pressing the knee directly outwards. Lastly, the surgeon freely 
flexes the thigh upon the pelvis by thrusting the knee upwards 
toward the face of the patient, and at the same moment the abduction is 
to be increased. 

"Professor N". Smith regarded the free flexion of the thigh upon 
the pelvis as a very important part of the compound movement. He 
believed that it threw the head of the bone downwards, behind the 
acetabulum, where the margin of the cup is less prominent, and over 
which, therefore, the abductor muscles would drag it with less diffi- 
culty into its place. 

" The operator may slightly vary these movements, as he increases 
them, so as to give some degree of rocking motion to the head of the 
os femoris, which will thereby be disengaged with the more facility 
from its confined situation among the muscles." 1 

Dr. Luke Howe, of Boston, who was a pupil of Nathan Smith's, 
gives the following account of the method practised by him success- 
fully, about the year 1820, and which method, he says, was recom- 
mended by his preceptor : " The patient was permitted to lie on his 
back on the bed where I found him, the knee of the luxated limb 

1 Medical and Surgical Memoirs, by Nathan Smith., late Prof, of Surgery, &c, in 
Yale College. Edited by Nathan R. Smith, Prof, of Surgery in Univ. of Maryland. 
Baltimore, 1831, pp. 163-182. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 645 

turned in and over the other. I raised the knee in the direction it 
inclined to take, which was toward the breast of the opposite side, 
till the descent of the head of the bone gave an inclination of the 
knee outwards, when I made use of the leg, being at right angle with 
the thigh, as a lever to rotate the latter and turn the head of it in- 
wards. It then readily returned to its socket, with an audible snap. 

Fig. 262. 




Nathan Smith's method of reduction hy manipulation. (From Smith's "Memoirs.") 

During this operation, the two assistants who had been placed to 
make the lateral extension and counter-extension, if ultimately re- 
quired, were directed to draw moderately at their towels. How much 
of the success of the operation is to be imputed to their extension, and 
the rotation of the thigh by the leg, I am unable to determine ; but as 
Dr. Smith succeeded without the aid of either, and as the head of the 
femur seemed to descend by an easy and natural process, I am inclined 
to believe that all that is necessary, in such cases, is to elevate the 
knee, when the ilium, the muscles attached to it, and perhaps the 
ligament, become the natural fulcrum, over which the thigh, as a 
lever, acts to bring the head down and inwards into the socket." 1 

Kluge, in 1825, combined moderate extension with manipulation, 
by flexing both the leg and thigh, while at the same moment the 
thigh was abducted and the knee rotated inwards. 2 Wathman, in 
1826, directed that in this dislocation the limb should be seized by 
the knee and ankle and slowly lifted forwards until it. came to a right 

1 Howe, Boston Med. and Surg. Journ., vol. xxii. p. 249, May, 1840. 

2 Chelius's Surg., by South, Auier. ed., vol. ii. p. 241. 



6±Q DISLOCATIONS OF THE THIGH, 






angle with the long axis of the body ; when, if the ontward " self- 
twisting of the thigh" occurs, " which cannot be prevented by fast 
holding," the movement of the head of the bone is declared, and it 
will only remain for the surgeon to let down the thigh gradually 
upon the bed so that the two limbs will come side by side, and the 
reduction will be accomplished. 1 

Bust recommended also, in 1826, a similar plan, combining mode- 
rate extension by the hands, with flexion and abduction of the thigh. 2 

Colombat, whose opinions date from 1830, suggested that the pa- 
tient should lay himself forwards upon a bed or table, no higher than 
his hips, with the sound leg and foot resting upon the floor, and that 
then the surgeon seizing the foot with one hand, so as to flex the leg, 
should, with the other hand, exercise a moderate degree of extension, 
and at the same time move the limb to the right or to the left, backwards 
and forwards, in order to disengage the head of the femur ; and, finally, 
that he should communicate to the thigh a sudden movement of cir- 
cular rotation, either from within outwards, or from without inwards, 
as the surgeon may choose. 3 

Collin states that, in 1833, he had reduced four dislocations of the 
hip by a method very similar to this recommended by Colombat. 4 

Dr. William Ingalls, of Chelsea, Mass., reduced a compound dislo- 
cation of the femur, in which the head of the bone rested upon the 
pubes, after an unsuccessful attempt had been made to reduce it by 
extension. "An assistant, taking the ankle of the dislocated limb in 
his right hand, and placing his left in the ham, bent the leg at right 
angles upon the thigh, and the thigh upon the pelvis, then lifting with 
a power little more than sufficient to elevate the whole limb, he car- 
ried it to its greatest state of abduction, at the same time rotating the 
femur inwards, while Dr. Ingalls passed his thumb through the wound, 
and pressing upon the head of the femur, directed it toward the ace- 
tabulum. At this moment he directed the limb to be forced toward 
its fellow, by which the reduction was effected with the greatest pos- 
sible ease and elegance." 5 

Similar methods of reduction, with only such slight variations as 
scarcely deserve a special notice, have been suggested and practised 
from time to time by Palletta, in 1818 ; 6 Desprez, in 1835 ; 7 Yial, in 
1841 ; 8 Fischer, Mahr, and Clarke, in 1849. 9 

In 1851, Dr. W. W. Eeid, of Eochester, N. Y., published an account 
of the method practised by himself successfully in three cases of dis- 
location upon the dorsum ilii, the first of which dated from the year 
1844. His method, as applied to a dislocation upon the dorsum ilii, 
consists in " flexing the leg upon the thigh, carrying the thigh over 

1 Clielius's Surg., by South, Amer. ed., vol. ii. p. 240. 

2 Ibid., p. 241, note by South. 3 Malgaigne, op. cit., vol. ii. p. 825. 

4 Malgaigne, op. cit., p. 823. 

5 Ingalls, Bransby Cooper's ed. of Sir Astley's English ed., 1842, and Amer. ed., 
1852. 

6 Clielius's Surg. ; note by South. ? Malgaigne. 

8 Ibid. 

9 Dublin Med. Press, Dec. 3, 1851. New York Journ. Med., March, 1852. 



UPWARDS AIS T D BACKWARDS ON THE DORSUM ILII. 647 

the sound one, upwards over the pelvis as high as the umbilicus, and 
then abducting and rotating it." 1 

Dr. Markoe, of New York, adopts the same procedure, except that 
when the limb has been sufficiently flexed and abducted, he directs 
that the limb shall be gradually brought down, and he affirms that it 
is during this last manoeuvre that he has usually found the bone re- 
sume its place in the socket. 2 

Reduction by extension dates from a period equally early with re- 
duction by manipulation. Hippocrates recommended, when other and 
gentler means had failed, to make extension and counter-extension ; 
the extending bands being made fast above the knee and above the 
ankle, so as to distribute the points of pressure ; and the counter-ex- 
tending bands being secured around the chest under the armpits, and 
also, if thought necessary, in the perineum of the sound side. 



Fig. 263. 




Hippocrates's mode of reducing dislocations of the hip by extension. 

Among the methods recommended and practised by Hippocrates, 
was sitting across the upper round of a ladder with a weight attached 
to the thigh of the dislocated limb ; or suspending the patient from a 
sort of gallows with the head downwards, and if the weight of the 
patient's own body proved insufficient, the surgeon might add his also ; 
a method which Hippocrates characterizes as " a good, proper, and 
natural mode of reduction, and one which has something of display in 
it, if any one takes delight in such ostentatious modes of procedure." 3 

With various modifications as to the position of the limb, and as to 
the points upon which the extending and counter-extending forces are 
to be applied, and with differently constructed appliances, surgeons 
have continued to employ extension down to this day. 

The great majority have regarded flexion of the thigh as essential 
to success ; some holding the limb only slightly flexed, and others in- 
sisting that a flexion should be increased to a right angle with the 
body. 

The French surgeons, including Boyer and Yidal (de Cassis), prefer 

1 Reid, Buf. Med. Journ., vol. vii., Aug. 1851, pp. 129-143. 

2 Markoe, New York Jourii. Med., Jan. 1855. 

3 Works of Hippocrates, Syd. ed., London, vol. ii. p. 641. 



648 



DISLOCATIONS OF THE THIGH. 



generally to apply the extending bands to the feet, in order that the 
muscles of the thigh may not be stimulated to contraction by the pres- 
sure of the bandages. Mr. Skey adopts the same method. 

Sir Astley Cooper, Samuel Cooper, B. Cooper, Fergusson, Miller, 
Pirrie, Brichsen, and the English surgeons generally, make fast the 
lacq above the knee. J. L. Petit and Duverney, among the French, 
and Dorsey, Gibson, with most of the American surgeons, recommend 
the same, but Gerdy seeks to multiply the points of application, and 
for this purpose secures the extending band to the whole length of 
the leg, and to a small portion of the thigh above the knee. 

The counter-extending bands are now almost universally made to 
operate against the perineum of the dislocated limb, but Roux, follow- 
ing the practice of Hippocrates, places it in the perineum of the sound 
limb. Gibson recommends the same practice. 

Lizars recommends that sometimes the reduction should be attempted 
by simply placing the heel in the perineum and making the exten- 
sion with the hands, very much as Sir Astley Cooper advises us to 
proceed in dislocations of the humerus. Morgan and Cock, of Guy's 
Hospital, have reduced six cases of dislocation of the hip-joint by 
placing the foot between the thighs, so that it pressed against the 
upper part of the dislocated bone, and thrust it away from the pelvis ; 
extension and rotation of the limb being made at the same time by 
assistants. 1 Three of these were examples of dislocation upon the 
dorsum ilii, two upon the pubes, and one into the foramen thyroideum ; 
and most of them had occurred in weak or elderly persons. 

Ambrose Pare was among the first to recommend the use of pulleys 
for the reduction of dislocations. Most surgeons since his day have 
employed them for the purpose of making extension more energetic 
and steady, and that it might be longer continued. Sir Astley 
Cooper's plan of procedure is as follows : — 

The patient having been bled freely and the muscles still farther 

Fig. 264. 




Reduction of a dislocation on the dorsum ilii, by pulleys. 

relaxed by nauseating doses of antimony and by the hot bath, he is to 
be placed on his back upon a table of convenient height between two 



1 Cock and Morgan, Chelius, op. cit., vol. ii. p. 242, note by South. 



UPWAKD8 AND BACKWARDS ON THE DORSUM ILII. 649 

staples ; a strong padded leathern girth or perineal band, constructed 
so as to receive the thigh and to press at the same moment against the 
perineum and the outer surface of the pelvis, is then applied and made 
fast to one of the staples situated behind the patient in the direction of 
the axis of the limb. A wetted linen roller is next to be tightly 
applied just above the knee, and upon this a leathern strap is to be 
buckled, having two short straps with rings at right angles with, the 
circular part; or instead of this, a round towel made in the knot 
called the clove-hitch. The knee is to be slightly bent, but not quite 
to a right angle, and brought across the opposite thigh a little above 
the knee. The pulleys being now attached, the extension is to be 
commenced. 

A very simple and efficient mode of making the extension, if one 
has not the pulleys, is to employ for this purpose a small rope, the 
ends being tied together and the rope being then doubled upon itself 
once or twice, so as to make four or eight parallel cords. The oppo- 
site ends of this bundle of ropes being made fast to the limb and the 

Fig. 265. 




„. T m.. #1111 

Eeduction of a dislocation on the dorsum ilii, by the Spanish windlass. (Gilbert.) 

staple, the extension is made by thrusting a stick through its centre 
and twisting it. 

I have several times had occasion to resort to this plan ; and indeed 
it has been for some time known and practised among surgeons in this 
country, 1 having been first, according to Prof. Gilbert, introduced by 
Fahnestock, of Pittsburg, Pa. 

Jarvis's adjuster, to which I have already made allusion when speak- 
ing of dislocations of the humerus, has been often used with success in 
dislocations of the hip as well as in dislocations of the shoulder. 2 Its 
power is equal to that of the pulleys, while the direction of the force 

1 Gilbert, of Philadelphia. Note to Pirrie's Surg. ; also Amer. Journ. Med. Sci., vol. 
xxxv., April, 1845. 

* Crandall, Bost. Med. and Surg. Journ., vol. xxxix. p. 77 ; Atlee, Trans. Amer. Med. 
Assoc, vol. iii. 1850, p. 357. 

42 



650 



DISLOCATIONS OF THE THIGH. 



can be varied with much greater ease. The most serious objections 
to the instrument as employed for the reduction of dislocations, are its 
complexity and its expensiveness. 

Fig. 266. 




Jarvis's adjuster, applied for reduction of a dislocation of tlie hip. 

Mr. Fergusson says that the Lancet for July 26, 1845, contains a 
description of a similar apparatus constructed by Coxeter at the 
suggestion of G. N. Epps j 1 and L'Estrange, of Dublin, has invented 

Fig. 267. 




Bloxham's "dislocation tourniquet," applied for reduction of a dislocation on the pubes. 

a "windlass" for making extension, with a "forceps" by which the 
extending power can be instantly disengaged. 2 Mr. Bloxham's "dis- 
location tourniquet" is also very simple, and Mr. Erichsen affirms that 



Fergusson, 4th Arner. ed., p. 200. 



2 Ibid., p. 198. 



UPWARDS AND BACKWARDS OX THE DORSUM ILII. 651 

by it " any amount of extending force that may be required can be 
readily set up and maintained." 1 Sedillot, a French surgeon, has 
suggested that when pulleys are used, we should measure the exact 
power employed in the reduction, by an ingeniously contrived appa- 
ratus called the dynamometer. 2 Such an instrument might occasionally 
be useful in preventing the application of excessive force, especially 
when the patient is under the influence of an anaesthetic. 

Finally, without attempting to determine the precise relative value 
of these different procedures, all of which claim for themselves the 
testimony of experience, we are prepared to admit that no one of them 
is without merit, and that each may in certain cases possess advantages 
over the others. Precisely what the cases are to which each individual 
method may be especially applicable, we believe it would be impossi- 
ble to declare unless the cases were actually before us ; and even then, 
it would probably be found difficult to say which was the best until a 
fair trial of one or more, and a final success, had determined the ques- 
tion. The time has not yet arrived in which we may institute a rigid 
comparison between the relative merits of the two leading plans of 
reduction, manipulation, and extension, for while it is true that reduc- 
tion by manipulation has been practised from the earliest day, it is 
equally true that extension has been generally preferred and practised 
by surgeons in all ages, and especially since Sir Astley Cooper gave 
his admirable instructions upon the method of applying extension and 
counter-extension. Indeed it was not until Dr. Reid, of Rochester, 
again called the attention of the profession to this subject, illustrating 
his views by the results of several successful experiments and by in- 
genious arguments, that reduction by manipulation could be said to 
have been fairly introduced as an established method of practice ; a 
large majority of all the cases upon record of reduction by manipula- 
tion having been reported since the year 1851, the period of Dr. 
Reid's first communication to the Buffalo Medical Journal. 

The following summary of a paper prepared by myself, with the 
view of determining, if possible, the relative value of the two methods, 
and exhibiting an analysis of sixty-four cases in which manipulation 
was employed, will enable the reader to form some estimate of the 
difficulty in which this subject is involved ; and if it does not actually 
decide a moot- point, it will at least demonstrate that the method by 
manipulation is not without its hazards. 3 

"Of forty-one cases in which the fact is stated, twenty-eight were 
reduced on the first attempt, seven on the second, four on the third, 
and two on the seventh. In seven examples the head of the femur 
has been thrown from one position to another upon the pelvis, travel- 
ling from the dorsum of the ilium to the ischiatic notch, and from 
thence to the foramen ovale ; or directly from the dorsum to the fora- 
men, and back again; or in other directions, according to the character 

1 Erichsen, Amer. ed., 1858, p. 242. 

2 Amer. Journ. Med. Sci., vol. xv. p. 530. 

3 Reduction of Dislocation of the Femur by Manipulation. By the Author. Buffalo 
Medical Journal, Nov. 1857 ; Feb., March, June, 1859. With tables constructed by 
my very intelligent pupil, Lucien Damainville. 



652 DISLOCATIONS OF THE THIGH. 

of the original dislocation; in some instances these changes being 
made as often as seven times in succession. In the majority of cases 
no evil consequences seem to have followed upon these changes of 
position. One of my own cases will especially serve to show with 
what impunity sometimes these changes may be made. 

" John Caswell, set. 28, was admitted to the Buffalo Hospital of the 
Sisters of Charity on the 13th of January, 1858, with a dislocation of 
the left femur upon the dorsum ilii, which had occurred six days be- 
fore. His own account of the accident was that he was standing at 
the bottom of a well, bent forwards until his body was at a right angle 
with his thighs, when a bucket holding five hundred pounds of earth 
fell upon his back and hips. No attempt had been made to reduce 
the dislocation. Five times in succession manipulation made by my- 
self failed, leaving the head of the bone each time upon the dorsum 
ilii : the sixth attempt, made with the addition of moderate extension 
by the hands, threw the head into the foramen thyroideum. By revers- 
ing the movements, it was easily replaced upon the dorsum ilii. The 
seventh trial was made in the same manner, except that when I sup- 
posed the head of the bone to be opposite the lower margin of the 
socket I did not permit the limb to turn either outwards or inwards, 
but while lifting at the knee with my hands, with sufficient power to 
raise his hips from the table, I brought the limb down gradually to a 
line parallel with the opposite, and thus finally the reduction was 
accomplished. No pain or inflammation followed, and in two weeks 
he left the hospital; but whether he was able to walk or not at that 
time, I am unable to say." 1 

Since this paper was written the following cases have come to my 
knowledge. December 9th, 1865, Dr. James R. Wood attempted, at the 
Bellevue Hospital, the reduction of a dislocation of the femur upon 
the dorsum ilii of five months' standing, in a man sixty years of 
age, in the presence of Dr. Sayre, myself, and the class of medical 
students. The patient was under the influence of ether. Manipula- 
tion alone was employed. Probably half an hour had been consumed 
in the various efforts, when, at a moment when the thigh was being 
forcibly abducted, the neck was broken within the capsule, and very 
close to the head. I was able to feel the head of the bone distinctly, 
after the fracture, and to move it freely separated from the neck. 

Dr. Daniel Prince, of Illinois, who was present at the time, informed 
me that he had himself fractured the neck of the femur in attempting 
the reduction of an ancient dislocation of the hip by manipulation. 

" In Markoe's paper published in the New York Journal for January, 
1855, several similar cases are reported, in which the results have 
been equally fortunate; but the case mentioned as having been under 
the care of Dr. Post, of the New York Hospital, had a more serious 
termination. This patient, John Kelly, aet. 21, had a dislocation into 
the ischiatic notch, and on the same day the reduction was attempted 
by manipulation. On the first trial the head of the bone was thrown 
into the foramen ovale; and, after having been moved backwards and 

1 Buffalo Medical Journal, vol. xiii. p. 682. 



UPWARDS a:n t d backwards on the dorsum ilii. 653 

forwards between these two points several times, it was finally carried 
directly from the foramen ovale into the socket by manual extension 
applied in the ordinary way, but without pulleys. 'In this case,' says 
Markoe, 'the cure was very slow, and he left the hospital with some 
degree of pain and swelling about the joint. I learned that an abscess 
formed in or about the joint, which was opened, and when I saw him, 
a year after, there was every appearance of seated morbus coxarius." 
"In Case 14, of Markoe's paper, the thigh was broken at the neck 
after manipulation had been employed, but while extension was being 
made by the hands, united with 'a lifting outwards.' Whether the 
fracture was due to the extension, or to the manipulation, seems not 
to be clearly determined. The dislocation had existed seven weeks 
when this attempt at reduction was made. 

"So far as I am able to say, these are all the examples in which a 
serious injury has been, with any propriety, charged to the manipula- 
tion. 

"Assisted by my pupil, Mr. Hodge, I have also succeeded in collect- 
ing sixty-two cases of attempts at reduction by extension ; a great 
majority of which, we find, were reduced in the first trials; but five 
cases of recent dislocation were not reduced until after several attempts 
had been made. 

"In five cases the femur was broken. The first occurred in St. 
Thomas's Hospital, London. Ben. Whittenburg, set. 40, was admitted 
Nov. 4, 1827, with a dislocation into the ischiatic notch, of twenty-two 
weeks' duration. After bleeding, &c, had been practised, an attempt 
was made to reduce the bone by pulleys, in which the reporter pro- 
fesses to believe they were successful, but on the following day it was 
plainly enough not in place. Mr. Travers again resorted to extension, 
and while extension was kept up and the assistants were rotating the 
limb outwards, the neck of the femur gave way. 1 Malgaigne mentions 
a case in which, while he was himself directing the operation, the thigh 
was broken through its lower third. He was attempting to reduce the 
bone by extension, but it was not until he gave the signal for rotation 
outwards that the bone gave way. 2 Gibson says that Dr. Physick, at 
the Pennsylvania Hospital, while engaged in reducing a dislocated 
thigh by the pulleys, broke the femur in consequence of exerting too 
much force upon it in a lateral direction by an additional pulley ; and 
that a similar accident is supposed to have happened to Drs. Harris 
and Eandolph in the same hospital, in the year 1838, while using the 
pulleys upon a boy twelve years of age; for during extension and 
counter-extension, at the moment of rotating the limb, and of drawing 
it forcibly outwards by a towel, a sudden crack was heard. 3 

"The fifth case is related by Sir Astley Cooper, as having occurred 
at the Brighton Hospital, under the care of Mr. Gwynne; the dislo- 
cation was upon the dorsum ilii, and was supposed to have existed 
about one month. The neck of the femur was broken in the first at- 

1 London Med.-Chir. Rev., Nov. 1828, p. 239. 

2 Malgaigne, op. cit., vol. ii. pp. 146 and 830. 

3 Gibson's Surgery, sixth ed., vol. i. p. 389. 



654: DISLOCATIONS OF THE THIGH. 

tempt at reduction, and while the surgeon was making extension, with 
gentle rotation. 1 

"Sir Astley says: 'There are plenty of cases upon record, of fatal 
abscesses from violent attempts at the reduction of dislocated hips.' 
We presume that this remark has reference to attempts at reduction 
by extension, since, in his day, this was almost the only mode in use 
among surgeons. He adds, moreover, that Mr. Skey has mentioned, 
in the Lancet, 2 a fatal case of phlebitis following protracted extension 
of the hip. 

"Malgaigne has collected no less than eight similar examples, with 
several more in which serious consequences and even death followed 
promptly upon violent attempts at reduction by mechanical means. 3 

"The head of the bone has been repeatedly thrown from the dorsum 
ilii into the ischiatic notch, and B. Cooper mentions a case in which 
the bone was carried from the foramen ovale into the ischiatic notch, 
from which latter position it could not afterwards be changed. 4 

" As to the relative chances of failure by the two methods, the testi- 
mony of the recorded cases is equally unsatisfactory. Of the failures 
by extension, the experience of almost every surgeon, the journals and 
the treatises furnish a sufficient number of examples; while among 
the sixty-four cases of attempts at reduction by manipulation collected 
by me, and excepting the cases in which the bone was broken, only 
two were positive failures. It is somewhat remarkable, however, that 
these two cases occurred in the experience of the New York City Hos- 
pital ; and that they are taken from a total of fifteen, this being the 
whole number which had been treated by this method at the date of 
these observations, in the New York Hospital. One had existed one 
month, and after repeated trials by manipulation and frequent changes 
of position, it was finally reduced by pulleys. The other, a dislocation 
into the ischiatic notch, had existed only a few hours. At least seven 
or eight trials were made to accomplish the reduction by manipulation, 
but without success. The first attempt by extension failed also, but 
in the second attempt the femur was kept at a right angle with the 
body, and the bone was soon brought into its socket. 5 

"We have in these two examples, not only a record of failure by 
manipulation, but an equal record of success by extension ; while, on 
the other hand, we find in an analysis of the sixty-four cases, sixteen 
triumphs of manipulation over extension. 

" We must not omit to mention, in order that the reader may form 
a just estimate of the value of these statistics, that the great majority, 
especially of the cases treated by manipulation, have occurred in 
private practice, and it is unnecessary to say that such statistics do 
not furnish the most reliable basis for conclusions. As a general rule, 
unsuccessful cases are not published by private practitioners, but suc- 
cessful cases are pretty certain to be made known; while, on the other 

1 Sir Astley Cooper on Disloc, &c, Amer. ed., p. 88. 

2 Op. cit., vol. i. p. 7137, 1840-41. Cooper on Disloc, p. 69. 

3 Malgaigne, op. cit., vol. ii. p. 164 et seq. 

4 Sir Astley Cooper on Disloc. By Bransby Cooper, Amer. ed., p. 96. 

5 Van Buren, New York Med. Times, Jan. 1856, p. 126. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 655 

hand, a series of cases furnished by any single hospital will generally 
be found to have given both unsuccessful and successful cases. The 
writer has heard lately of a complete failure to reduce by manipulation 
in a recent luxation of the hip, after repeated efforts on several succes- 
sive days, and where skilful surgeons were in attendance; but it is 
believed that no account of the result has been published. 

"We have alreadjr called attention to the fact that, in the New York 
City Hospital, two of the fifteen cases reported were failures ; a cir- 
cumstance of remarkable significance, especially when we consider the 
skill of the several gentlemen who were the operators in these cases ; 
and it plainly renders a new series of statistics necessary, drawn solely 
from the experience of one or more similar large establishments, before 
we shall be prepared to decide positively upon the relative value of 
the two procedures. 

"Nevertheless, we shall not hesitate to express our present convic- 
tions upon this subject, reserving to ourselves the right of a change of 
opinion whenever the proofs shall warrant it. 

" Manipulation, owing to the greater power which may be brought 
to bear upon the neck and head of the bone through the action of the 
shaft of the femur as a lever, is most liable to throw the head, of the 
bone into new positions, and consequently most liable to rupture the 
various soft tissues about the joint, to produce inflammation, suppura- 
tion, and caries. For the same reason it is most liable, also, to fracture 
the neck of the femur. It is not certain in our mind but that, when 
the principles which control the reduction are more completely under- 
stood, these evils may be lessened ; yet we can scarcely persuade our- 
selves that by any future observations, the state of the question will 
ever be greatly changed. We cannot but think, also, that some con- 
clusions ought to be drawn from the circumstance that, since the time 
of Hippocrates to the present day, manipulation has been occasionally 
recommended and successful examples reported ; the reduction being 
accomplished in most instances by processes identical, or nearly so, 
with those now adopted ; yet generally the writers appear to have 
been ignorant of what had been done before, and, indeed, they have 
generally avowed their belief that the method suggested by themselves 
was altogether new and original. Possibly, this slowness to establish, 
and total inability to sustain and perpetuate a reputation, was not the 
fault of the method, and had no relation to its failures. Until within 
a few years, the number of surgical books, and especially of medical 
journals, was comparatively very small, so that valuable truths often 
died with their discoverers, or were known and remembered only by 
a few ; but it is possible, also, that it has a deeper significance, and that 
it implies some defect in the procedure, or serious danger, in conse- 
quence of which it has from time to time lapsed into desuetude and 
finally into complete oblivion." 

The rules which the author would give for the employment of 
manipulation are very simple. 

The patient being laid on his back upon a mattress, the surgeon, 
assuming that it is a dislocation upon the dorsum ilii, should seize the 
foot with one hand and the other he should place under the knee ; 



656 DISLOCATIONS OF THE THIGH. 

then, flexing the leg upon the thigh, the knee is to be carefully lifted 
toward the face of the patient until it meets with some resistance ; it 
must then be moved outwards and slightly rotated in the same direc- 
tion until resistance is again encountered, when it must be gradually 
brought downwards again to the bed. We do not know that the 
whole process could be expressed in simpler or more intelligible terms, 
than to say, that the limb should follow constantly its own inclina- 
tion. 

All writers have united in the necessity of flexion ; and, indeed, 
with very few exceptions, the advocates of extension have insisted 
upon carrying the dislocated limb more or less across the sound one ; 
they have also been nearly unanimous in their statements that the 
thigh should then be abducted and finally brought down. Nathan 
Smith has added the injunction to rotate the shaft of the femur out- 
wards, and to press gently upon the inside of the knee while the thigh 
is being flexed upon the body, so as to compel the head of the bone 
to hug the outer margin of the acetabulum and to prevent its falling 
into the ischiatic notch ; a suggestion which has been erroneously in- 
terpreted by some writers to mean that he would carry up the limb 
abducted, a thing which is simply impossible until the reduction is 
accomplished. In adopting this practice, however, we must not forget 
the danger which we incur when the limb is completely flexed, and 
the head of the femur is below the edge of the acetabulum, of throwing 
it over into the foramen ovale. Dr. Nathan Smith has also noticed 
the advantage which sometimes may be gained by giving to the limb 
at this moment a slight rocking motion. 

These movements of the limb, with perhaps other slight modifica- 
tions, such as lifting the knee moderately when the bone refuses to 
mount over the margin of the acetabulum, pressing with the hand 
upon the head of the bone, &c, are all which have been usually prac- 
tised in successful manipulation. 

We repeat, however, that as a general rule, the knee must be car- 
ried only in those directions which offer no resistance, and these will 
be found almost always to be the same ; the knee of the dislocated 
femur hanging over the sound one will be made easily to ascend to 
about a right angle with the body, we can then carry it outwards a 
short distance, probably not more than four or five degrees ; at this 
moment, frequently the thigh will begin to rotate outwards of itself, 
and with considerable force, or as Wathman says, " a self-twisting of 
the thigh occurs, which cannot be prevented by fast holding." When 
this action takes place the reduction is immediately accomplished ; 
and it is in fact at this moment, before the limb begins to descend, 
that the bone most frequently resumes its socket. If it does not, then 
as soon as the limb begins to fall the reduction occurs; generally with 
a loud snap. It is pretty certain that this manipulation is to fail if 
the knee has descended more than a few inches without the reduction 
having taken place ; and it will be better to repeat the manoeuvre at 
once, rather than to bring the limb completely down. 

Generally anaesthetics ought not to be employed, since the opera- 
tion, if successful, is not usually painful, and we need that the patient 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 657 

should preserve his consciousness in order to admonish us when we 
are using improper violence. It is probable, also, that the action of 
certain muscles sometimes affords material assistance in the reduction. 
If, however, the patient is very sensitive, or the parts about the joint 
are very tender, or manipulation without anaesthetics has failed, then 
certainly these agents may be properly and advantageously employed. 

If we propose to attempt reduction by extension, it is no longer 
necessary to resort to the lancet, antimony, and the hot bath, as pre- 
liminary measures, since the muscles can be at once overcome- by the 
much more certain and more powerful agents, chloroform, ether, &c. 

The patient is therefore to be placed at once upon a bed of suitable 
height, reclining on his back, but partly over upon the sound side. 
Observing now the line of the axis of the dislocated thigh, one strong 
staple is to be secured into the wall upon one side of the room, and 
another upon the opposite side, both of which shall correspond as 
nearly as possible with the line of the shaft of the femur. The staple 
in front of the body will be higher than the bed, and the staple behind 
will be, in the same proportion, lower than the bed. The limb being 
stripped, two pieces of strong factory cloth, each about four inches 
wide and two feet long, should be laid parallel with and on each side 
of the limb ; the centre of each strip being about opposite that portion 
of the thigh which is just above the two condyles. Over the centre 
of these strips, above the condyles and patella, a strong roller, three 
inches wide and at least three yards long, previously wetted in water, 
is to be turned as tightly as it can be drawn until the whole roller is 
exhausted ; the extremity of the roller being made fast with a needle 
and thread rather than with pins. The upper ends of the side strips 
are then to be brought down, and tied to the lower ends, forming 
thus two lateral loops, upon which one of the hooks of the compound 
pulleys is to be made fast, while the other hook is secured to the front 
staple in the wall. Instead of these rollers we may employ, if we 

Fig. 268. 



Keduction of dislocation upwards and backwards upon the dorsum ilii, by the pulleys and thigh belt. 

choose, a leathern thigh belt. For the purpose of counter-extension 
a sheet is folded diagonally, and its centre being applied to the peri- 



653 DISLOCATIONS OF THE THIGH. 

neum of the dislocated limb, the ends are tied firmly into the back 
staple. To prevent the body from moving laterally, under the action 
of the pulleys, one assistant should be seated upon the bed, with his 
back against the side and back of the patient, and his right arm 
thrown over the body ; it is well also to station another beside the 
sound limb, so as to retain it also in its place upon the bed. Under- 
neath the upper part of the dislocated limb a strong and broad band- 
age should be placed, of sufficient length to tie over the neck of the 
surgeon when he is standing about half bent over the body of the 
patient. 

Everything being arranged, and all portions of the apparatus having 
been sufficiently tested to make sure that nothing will give way during 
the operation, the anaesthetic is to be administered, and as the patient 
falls gradually under its influence, the action of the pulleys should 
commence, and be slowly but steadily increased; a third assistant 
managing the rope, so as to leave the surgeon unembarrassed, and able 
to direct his whole attention to the position of the trochanter major 
and of the head of the femur. In order to this, he should place one 
hand upon each of these prominences, and watch carefully their de- 
scent. 

The length of time which will be required to bring down the limb 
must differ greatly in different persons, according to the peculiar cir- 
cumstances of the case, and the condition, age, &c, of the patient ; but 
it must never be forgotten that a slow and steady action is much more 
effective than rapid and irregular tractions, and it is in this especially, 
rather than in the relative amount of power, that the pulleys possess 
always so great an advantage over the hands. 

"When the surgeon finds that the head of the bone has nearly or 
quite reached the socket, if it does not take its place spontaneously, 
he may place his neck in the noose which passes underneath the thigh, 
and lift upwards, in order to raise the trochanter major, and thus 
enable the head to rotate toward the acetabulum. It is in this part of 
the manoeuvre, and especially when at the same moment one of the 
assistants, after bending the leg upon the thigh so as to make of it a 
lever, has rotated the thigh outwards, that the fracture of the neck 
has generally taken place ; and we cannot be too cautious, therefore, 
particularly in old persons, not to bear very strongly upon the noose, 
nor to permit the assistant to rotate outwards with great force. 

If the bone does not enter the socket, we may increase or diminish 
the flexion, or suddenly release the tension, or, in fine., again resort to 
manipulation alone. 

When the reduction is accomplished, the patient should be laid 
upon his back, with the knees resting over a pillow, and tied together 
lightly with a towel or a strip of cotton cloth. In order also the more 
certainly to prevent a reluxation, the thigh of the dislocated limb 
should be gently rotated outwards, by which the head will be pressed 
forwards against the anterior portion of the capsule. 

Such an accident, however, as a recurrence of the dislocation, in 
the case of the femur, is exceedingly rare; and I should have deemed 
it altogether impossible, except as the result of considerable violence 



UPWARDS AND BACKWARDS INTO ISCHIATIC NOTCH. 659 

again applied, had not at least two examples been reported to us 
upon very excellent authority. Malgaigne says he has himself seen 
an example of reluxation upon the dorsum ilii, occasioned by an un- 
timely movement ; : and Verneuil has seen, six days after the redaction 
of a dislocation upon the ischiatic notch, the dislocation reproduced 
by a sudden effort of the patient to sit up. 2 

Of course, in these remarks we mean to except those cases in which 
the upper margin of the acetabulum is broken ofrj and the head of the 
femur has consequently lost its natural support in this direction. 

The possibility of this accident is also confirmed by the examples 
of "voluntary" dislocations which I shall relate in the last section of 
this chapter. 



Fig. 269. 



§ 2. dslocattons upwards and backwards into the great ischiatic 

Notch. 

Syn. — "Upwards and backwards into the ischiatic notch ;" Sir A. Cooper. "Up- 
wards and backwards into the great sacro-sciatic notch ;" Lizars. " Backwards into 
the sacro-sciatic foramen ;" S. Cooper. " Backwards into the ischiatic notch ;" Liston, 
B. Cooper, Miller, Pirrie, Erichsen, Skey, Gibson. " Downwards and outwards on the 
os ischium ;" Boyer, Dorsey. " Backwards and downwards into the ischiatic notch ;" 
Chelius, Petit, Duverney. " Upon the ischium ;" Bertrandi. "Sacro-sciatic ;" Grerdy. 
"Ischiatic;" Malgaigne. 

Boyer considers this dislocation as only secondary upon a disloca- 
tion upon the dorsum ilii ; but it is very certain that it often occurs 
as a primary accident. Not unfre- 
quently, also, what was primarily a 
dislocation into the ischiatic notch, 
becomes subsequently a dislocation 
upon the dorsum ilii. 

Causes. — A fall upon the foot or 
knee, when the limb is very much in 
advance of the body ; or the fall of a 
heavy weight upon the back and'pelvis 
when the thigh is nearly or quite at a 
right angle with the body. Indeed 
the causes are very similar to those 
which produce dislocations upon the 
dorsum ilii, except that it is necessary 
to suppose the limb in a position more 
nearly at a right angle with the trunk, 
at the moment in which the force is 
applied. 

Pathological Anatomy. — Mr. Syme, 
who dissected the body of a man re- 
cently dead, whose thigh had been 
dislocated into the ischiatic notch, 
found the gluteus maxim us nearly 
torn asunder, the head of the femur 




Dislocation upwards and backwards into 
the great ischiatic notch. (From A. Cooper.) 



Malgaigne, op. cit., torn. ii. p. 830. 2 T bicL) p> §49. 



660 



DISLOCATIONS OF THE THIGH. 



being imbedded in its substance; the glutseus minimus, the pyriformis, 
and the gemellus superior lacerated; the capsular ligament extensively 
torn close to the edge of the acetabulum, and the round ligament com- 
pletely separated from the femur. The head of the femur was lying 
in the great ischiatic notch, upon the gemelli and the sacro-sciatic 
nerve, behind the acetabulum and a little above it; being situated 
between the upper margin of the notch, and the great sacro-sciatic 
ligaments. 1 Figure 269 is a representation of this specimen. 

Dr. Joseph C. Hutchinson, of Brooklyn, N. Y., has reported an ex- 
ample of this dislocation in which death having occurred four days 
after reduction, he was able to ascertain the character of the lesions. 

By the courtesy of Dr. 



Fig. 270. 




Dislocation upwards and backwards, into the great ischiatic 
notch. 



H., I was permitted to be 
present at this autopsy, 
and the lesions were 
found to be much the 
same as in the case related 
by Syme ; but the gluteus 
minimus was not torn, 
and there was added a 
laceration of the obturator 
externus. Dr. Lente has 
reported one other dissec- 
tion made after reduction. 2 
Symptoms. — The posi- 
tion of the limb is in some 
cases nearly the same as 
in certain dislocations 
upon the dorsum. It is 
shortened usually about 
half an inch, the thigh 
being flexed upon the 
body, adducted and ro- 
tated inwards; but the 
flexion is usually less 
than in dislocations upon 
the dorsum, while on the 
other hand, it is some- 
times much greater. 
Generally it is such that 
when the patient is stand- 
ing the end of the great 
toe of the dislocated limb 
touches the ball of the 
great toe of the sound 
limb. The head of the 
femur may also often be 



1 Amer. Journ. Med. Sci., vol. xxxii. p. 460. 

2 Lente, New York Journ. Med., Jau. 1651. 



UPWARDS AND BACKWARDS INTO ISCHIATIC NOTCH. 661 

distinctly felt in its new position, especially when the limb is moved 
upwards or downwards. The trochanter major is approximated to- 
ward the anterior superior spinous process of the ilium. 

Sir Astley Cooper remarks that this dislocation is the most difficult 
to detect and to reduce, and Mr. Syme mentions a case in which the 
nature of the accident was overlooked by himself, and the thigh was 
not reduced until the thirteenth day ; x and subsequently Mr. Syme has 
called attention to what he considers as one of the most important 
diagnostic marks; indeed, he says it is never absent, nor is it ever 
met with in any other injury of the hip-joint, "whether dislocation, 
fracture, or bruise;" this is "an arched form of the lumbar part of the 
spine, which cannot be straightened so long as the thigh is straight, or 
on a line with the patient's trunk. When the limb is raised or bent 
upwards upon the pelvis, the back rests flat upon the bed; but so soon 
as the limb is allowed to descend, the back becomes arched as before." 2 
This position, assumed by the back when an attempt is made to 
straighten and depress the limb, is due to the action of the psoas 
magnus and iliacus internus. But in addition to this valuable sign, 
the inversion of the toes, immobility of the limb, and the absence of 
crepitus, are generally sufficient in themselves to distinguish it from a 
fracture of the neck. Dr. Squires, of Elmira, N. Y., in a note addressed 
to me in March, 1860, suggests, also, that in ancient cases the projec- 
tion of the head of the femur may be felt by passing the finger into 
the rectum or vagina. In this way Dr. Say re and myself determined 
a dislocation into the ischiatic notch which had existed six months in 
a boy twelve years old; and Dr. Wood with myself diagnosticated the 
same dislocation in a woman at Bellevue Hospital, which had existed 
four weeks, in the same manner. 

Prognosis. — I have seen two dislocations of this character which, 
were not recognized by the surgeons at the time of the receipt of the 
injury, nor for some weeks afterwards. One was in a lad twelve years 
old, who was brought to me from an adjacent county in August, 1847. 
The accident had happened eight weeks before. His limb was short- 
ened one inch; it was also forcibly adducted and rotated inwards. 
Dr. Colegrove, a very excellent surgeon, had made a thorough attempt 
to reduce the dislocation with pulleys a few days before he was brought 
to me, and I did not deem it advisable to subject him again to the trial. 
Notwithstanding the dislocation his limb was quite useful. The second 
was in the case of the boy seen by Dr. Sayre and myself to which I 
have just referred. 

Treatment. — In employing manipulation, we may follow, with only 
a slight modification, the directions already given in dislocations upon 
the dorsum ilii. We find the head of the femur lower, consequently 
the extent of the circuit to be described in the manoeuvre is diminished, 
but in other respects the processes are identical. 

We must not forget, however, that there is especial danger, while 

1 Amer. Journ. Med. Sci., vol. xviii. p. 242. 

2 Amer. Journ. of Med. Sci., Oct. 1843. p. 461, from Lond. and Edinb. Month. Journ., 
July, 1843. 



662 DISLOCATIONS OF THE THIGH. 

attempting to reduce this dislocation by manipulation, that the head 
of the bone will be thrown across into the foramen thyroideum. I 
have already mentioned one case occurring under the care of Dr. Post 
in the New York Hospital, in which the head of the femur, originally 
in the ischiatic notch, passed backwards and forwards between the 
ischiatic notch and the foramen ovale many times, and which, although 
the reduction was finally accomplished, was followed by morbus coxa- 
rius. Parker mentions a second case in the same paper, 1 in which his 
first attempt to reduce by manipulation carried the head of the bone 
into the foramen ovale ; but the second attempt was successful. In 
Dr. Hutchinson's case, to which I have already referred, the first 
attempt at reduction was made without an anaesthetic, and by manipu- 
lation after the method described by Eeid. The first two attempts 
failed, and in the third, the limb being more abducted than before, the 
head of the bone was thrown into the foramen ovale. By reversing 
the movements it was replaced in the ischiatic notch: and this change 
of position .was made seven or eight times. The patient was now 
etherized and the bone was lifted into its socket in the same manner 
which I have described in the case of Caswell. Malgaigne refers to a 
patient of Lenoir's, and- to another of his own, in which the head of 
the bone was lodged under the margin of the acetabulum during the 
attempts at reduction. 2 

On the 23d of March, 1855, Charles McCormick, set. 21, a laborer on 
the " State Line Ptailroad," was caught between two cars, with his back 
resting against one car, and his right knee against the other, the right 
thigh being raised to a right angle with his body. As the cars came 
together he felt a "cracking" at his hip-joint, and found himself im- 
mediately unable to walk or stand. 

Two hours after the accident, assisted by my son Theodore, and 
Austin Flint, Jr., I examined the limb carefully, and made arrange- 
ments for the reduction with the pulleys, in case the attempt by mani- 
pulation should fail. 

The patient lying upon his back, I seized the right leg and thigh 
with my hands, the leg being moderately flexed upon the thigh, and 
carried the knee slowly up toward the belly, until it had approached 
within twelve or fifteen inches, when noticing a slight resistance to 
further progress in this direction, I carried the knee across the body 
outwards, until I again encountered a slight resistance, and immediately 
I began to allow the limb to descend. At this moment a sudden slip 
or snap occurred near the joint, and I supposed reduction was accom- 
plished; but on bringing the limb down completely, I found it was 
still in the ischiatic notch. I think the head had slipped off' from the 
lower lip of the acetabulum, after having been gradually lifted upon it. 

Without delay I commenced to repeat the manipulation, and in 
precisely the same manner. Again, at the same point, when the limb 
was just beginning to descend, a much more distinct sensation of slip- 
ping was felt, and on dropping the limb it was found to be in place 
and in form, with all its mobility completely restored 

1 Markoe's Paper, N. Y. Journ. of Med., Jan. 1S55. 

2 Malgaigne, op. cit., torn. ii. p. 839. 



UPWARDS AO BACKWARDS INTO ISCHIATIO NOTCH. 



663 



No anaesthetic was employed, and no person supported the body or 
interfered in any way to assist in the reduction. No outcry was made 
by the patient, yet he informed me that the manipulation hurt him 
considerably. The amount of force employed by myself was just 
sufficient to lift the limb, and the time occupied in the whole pro- 
cedure was only a few seconds. 

Fig. 271. 




Keduction of dislocation upwards and backwards into the great ischiatic notch, by extension. 



After the reduction he remained upon his back, in bed, eleven clays, 
in pursuance of my instructions. At the end of this time he began to 
walk about, but was unable to resume work until after eight weeks 
or more. It is probable that he could have walked immediately after 
the reduction, without much, if any inconvenience, so trivial was the 
inflammation which resulted from the accident. He never complained 
of pain, but only of a slight soreness back of the trochanter major, 
near the head of the bone. This soreness continued several weeks, 
and was especially present when he bent forwards. After the lapse 
of four months, when I last saw him, he occasionally felt a pain at 
this point in stooping, but the motions of the joint were free ; he walked 
rapidly and without halt. 

If the reduction is attempted by extension, we ought to remember 
that the head of the bone lies more behind than above the socket, and 
that it is not requisite to carry it downwards so much so as forwards ; 
and especially that it must mount over the most elevated margin of 
the socket, in order to resume its position. The extension ought, 



664c DISLOCATIONS OF THE THIGH. 

therefore, to be made at an angle of 45° ; and if this is not alone suffi- 
cient, the head of the bone should be lifted by a jack-towel upwards 
and in the direction of the socket. Bransby Cooper thought that the 
limb should be flexed quite to a right angle whilst the extension was 
being made ; but this can only be necessary when the head of the. bone 
is dislocated directly backwards. 

Care must be taken that the counter-extending band does not slide 
off from the pelvis, toward the upper part of the thigh, as it is con- 
stantly disposed to do, when the limb is so much flexed. This dis- 
position may be restrained, in some measure, by attaching . to the 
counter-extending band another band which shall pass off from the 
first at a right angle, and embrace the pelvis upon the opposite or 
sound side. 

Dr. Annan, of Baltimore, believes that the great difficulty which 
surgeons have experienced in their attempts to reduce this dislocation, 
has arisen from this malposition of the counter-extending band ; and 
as he has been unable to prevent its sliding off from the pelvis where 
the method of Sir Astley Cooper has been tried, he suggests the fol- 
lowing plan : The patient is to be placed upon his face on a table ; the 
pelvis secured by a band passing around it, and going off laterally at 
right angles from the sound side, to be fastened to a post or a ring 
fixed in the wall ; another band is to be put around the upper part of 
the thigh of the injured limb, which should be given to the assistants, 
or attached to the pulleys, in case they are to be employed ; this band 
also acting at a right angle with the axis of the body, but in the 
opposite direction, so as to antagonize the band which acts upon the 
pelvis. The extending band, made fast in the usual manner, above 
the knee, is then to be tightened, but only sufficiently to prevent the 
head of the bone from ascending. The ankle of the dislocated limb 
should now be laid hold of, and adducted, or drawn over the back of 
the sound limb ; " which," says Dr. Annan, " will force the head of 
the bone out of the notch, and make it describe the segment of a circle, 
and pass a little downwards in the direction of the acetabulum. Care 
must be taken," he adds, "that the extending band is sufficiently 
tightened, and that it does not yield, otherwise the drawing of the leg 
across the other will only move the head of the bone in the notch, as 
if it was a joint. If lateral extension only was employed in this case, 
the head of the femur would be drawn out of the notch, but it would 
ascend upon the dorsum of the ilium, above the acetabulum. Whereas, 
by simply drawing the limb laterally as much as is required to make 
the extending band serve as a fulcrum, and then using the leg as a 
lever, the head of the bone is not only forced inwards, but is moved 
downwards, and must necessarily pass into the socket." 1 

Lente relates a case under the care of Dr. Hoffman, in the New 
York City Hospital, in which, when the extension was suddenly re- 
laxed by cutting the cord, and the thigh, at the same instant, was 
abducted and rotated outwards, the head of the femur left the ischiatic 

1 Annan, Amer. Journ. Med. Sci., vol. xix. p. 382, Feb. 1837. 



INTO THE FORAMEN TH YKOIDE UI. 665 

notch, and rose upon the dorsum ilii, assuming a position directly 
above the acetabulum, and below the anterior superior spinous pro- 
cess ; and from which position it was subsequently, with great diffi- 
culty, returned to the socket. 1 

§ 3. Dislocations Downwards and Forwards into the Foramen 
Thyroideum. 

Sy n , — "Downwards into the foramen ovale;" Sir A. Cooper. "Downwards into 
the obturator foramen;" Lizars. "Downwards and forwards into the foramen obtu- 
ratorium ;" B. Cooper. "Inwards and downwards into the oval hole;" Chelius. 
" Downwards and forwards into the foramen ovale;" Pirrie. "Downwards and in- 
wards;" Boyer. "Sub-pubic;" Gerdy. " Ischio-pubic ;" Malgaigne. 

Causes. — In order to produce this dislocation the limb must be, at 
the moment of the receipt of the injury, in a position of abduction. 
Perhaps most often it is occasioned by the fall of a heavy weight upon 
the back of the pelvis when the body is bent and the thighs spread 
asunder. 

Pathological Anatomy. — The capsule gives way upon the inner side 
especially ; the round ligament is torn from its attachment, and the 
head of the femur pressing forwards and downwards, finds a lodge- 
ment upon the obturator externus muscle, over the foramen thyroi- 
deum. 

Symptoms. — The thigh is lengthened from one to two inches, greatly 
abducted and flexed, the body being also bent forwards or flexed upon 
the thigh. The dislocated limb is advanced before the other, and the 
toes generally point directly forwards, but they may incline either 
outwards or inwards. The hip is flattened ; the trochanter major is 
less prominent than upon the opposite side ; and the head of the bone 
may sometimes be felt in its new position. The lengthening of the 
limb alone is sufficient to distinguish this accident from a fracture of 
the neck. 

Treatment. — It is pretty certain that in the following example there 
was a spontaneous reduction, or rather, I ought to say, an accidental 
reduction of a dislocated femur from the thyroid foramen. Perhaps 
it was only an example of a partial luxation ; of which species of for- 
ward luxation I shall hereafter relate another case as having come 
under my own notice. 

Jacob Lower, set. 10, fell from a tree, a height of about twelve feet, 
to the ground. It is not known how he struck. He became imme- 
diately quite faint, and when he had partly recovered, he attempted to 
get up, but could not. He said his leg was broken, and cried out lus- 
tily whenever it was moved. The father arrived in about an hour, 
and found him still lying on his back where he had fallen, with his 
right leg carried away from the other, and turned outwards. He 
lifted him up to place him in a small hand wagon, which was long 
enough for his body, but only one foot and a half in width. Finding 
that his right leg was so much abducted as to prevent his being laid 

1 Lente, New York Journ. Med., Nov. 1850, p. 314. 
43 



DISLOCATION'S OF THE THIGH. 



in so narrow a space, he seized upon it, and with some force pressed 
the knee inwards across the opposite leg, when suddenly it resumed 



Fig. 272. 



Fig. 273. 





Dislocation downwards and forwards into the fora- 
men thyroideum. 

its position with a loud snap like a 
" cannon." I use the language of 
the father. On the following day I 
examined the limb carefully, and 
found its motions free. He was, 
however, vomiting the contents of 
his stomach, and passing blood 
from the bladder quite freely. The 
vomiting soon ceased, but the he- 
morrhage from the bladder contin- 
ued three or four days. On the 
ninth day he walked out, and on 
the twelfth he was seen climbing 

upon the top of a house. I saw him again after the lapse of a year, 
and found that he was still complaining of an occasional soreness in 
the region of the hip-joint. 

If we attempt to reduce by manipulation, it will be necessary to 
follow the same rule which we have stated as applicable to disloca- 
tions backwards, namely, to carry the limb only in those directions in 
which it is found to move easily. Instead, therefore, of holding the 
leg in a position of adduction while the thigh is flexed upon the abdo- 
men, it will be necessary to carry it up abducted; and when the further 
progress of the knee toward the belly is arrested, the limb must be 
moved inwards, and finally brought down adducted. When the knee 
is about opposite the pubes, or a little lower in its descent, the femur 



Dislocation downwards and forwards into the 
foramen thyroideum. 



INTO THE FORAMEN THYROIDEUM. 667 

should be gently rotated inwards for the purpose of directing the head 
toward the acetabulum. The reduction may also be sometimes facili- 
tated by giving to the shaft of the femur a slight rocking motion when 
it is about to enter the socket ; and also by pressing with the hand 
against the head of the bone, or by lifting at the knee moderately. 

In one of the examples recorded by Markoe (Case 8), the reduction 
was accomplished in the second attempt, by rotating the thigh inwards 
just as the thigh had descended below a right angle with the body, 
in the manner which we have above directed ; but in a second example 
(Case 9), a similar manoeuvre carried the head across into the ischiatic 
notch, while the reduction was finally accomplished by rotating the 
thigh outwards, and at the same moment adducting the limb strongly 
in a direction which carried the knee behind the other one. Markoe 
concludes that the latter mode is preferable, because it will throw the 
head of the bone a little upwards as well as outwards; in which direc- 
tion it will find a more gently inclined plane toward the socket. He 
admits, however, that both methods may accomplish the same result. 
But I am quite certain that the method by rotation of the shaft of the 
femur inwards is in general most likely to succeed. In this way also, 
I think, both W. H. Yan Buren, of New York, 1 and E. L. Brodie, of 
the U. S. Arm) 7 , were successful ; 2 but it is especially worthy of notice 
that Anderson, so long ago as 1772, in the case already quoted, when 
we were considering the history of reduction by manipulation, prac- 
tised successfully almost precisely the same method. In one example 
mentioned by Markoe (Case 7), it is pretty evident that the head of 
the femur was thrown into the ischiatic notch, by having flexed the 
thigh too much, so that "the knee touched the thorax." Indeed, it is 
questionable whether it will be best ever to bring the thigh much, if 
at all, above a right angle with the body, since any farther flexion can 
only throw the head below the acetabulum, when in fact it is already 
too low. 

July 21, 1858, Nathaniel Smith, a painter by trade, aet. 33, fell from 
the second story window of the city post office, upon a stone pave- 
ment, striking, as he believes, upon the inside of his right knee. I 
saw him within an hour, and found the right tibia partially dislocated 
outwards, the corresponding patella dislocated completely outwards, 
and the right femur in the foramen thyroideum. His thigh was forci- 
bly abducted ; slightly rotated outwards, and lengthened, by measure- 
ment made from the pelvis to the ankle, one inch and a half. The 
distance from the anterior superior spinous process to the fold of the 
groin was ten inches, but upon the sound side it was only eight and a 
half. The head of the femur could be distinctly felt in front, just 
under the pubes. 

Having administered chloroform, I first reduced the tibia and the 
patella, then seizing the thigh and leg, I flexed the thigh upon the 
body, carrying the limb upwards abducted until it was nearly or quite 
at a right angle with the body, then inclining the knee slightly in- 

1 W. H. Van Buren, New York Med Times, Jan. 1856, p. 127. 

2 R. L. Brodie, Memphis Med. Recorder, Sept. 1857, p. 90; from Charleston Med. Rev. 



668 



DISLOCATIONS OF THE THIGH 



wards, I brought it down again, and when the thigh had nearly reached 
the bed, it fell into its socket with a dull flapping sensation. In every 
step of the procedure I followed the inclination of the limb. The 
recovery was rapid and complete. 

Sir Astley Cooper says that this dislocation is in general reduced 
very easily by the aid of pulleys ; at least if the accident is recent. 




Sir Astley Cooper's mode of reducing a recent luxation into the foramen thyroideum. 

He advises that the patient shall be placed upon his back with his 
thighs separated as far as possible. The pulleys are to be made fast 
to a band drawn through the perineum of the dislocated limb, in a 
direction upwards and outwards; while a counter-band is to be passed 
around the pelvis through the band attached to the pulleys, and secured 
to a staple, or delivered to assistants placed upon the sound side of the 
body. When everything is arranged, the pulleys should be acted upon 
until the head of the femur is felt moving from the foramen ovale; at 
this moment the surgeon must pass his hand behind the sound limb, 
and seizing upon the ankle of the dislocated limb, adduct it forcibly, 
thus converting the limb into a lever of the first order. 

If the dislocation has existed some time, he recommends that this 
procedure shall be varied by placing the patient upon his sound side 
instead of his back, and attaching the pulleys perpendicularly over 
the body. Sir Astley especially cautions us not to flex the thigh during 
these manoeuvres, lest we force the head of the bone backwards into 
the ischiatic notch, from whence he affirms that it cannot afterwards 
be returned to its socket ; but the experience of surgeons has since 
shown that this latter statement is incorrect, and that it may, in some 



TJPWAKDS AND FORWARDS UPON THE PUBES. 669 

cases, be afterwards reduced, although it has fallen into the ischiatic 
notch. Mr. Liston says that this accident happened to himself while 
attempting to reduce a dislocation of only a few hours' standing, in a 
young and powerful man, but he had no difficulty in returning it to 
its first position. 1 

Brainard, of Chicago, reduced a dislocation of that form of which 
we are now speaking, after both the compound pulleys and Jarvis's 
adjuster had failed, by placing between the thighs a piece of wood 
wrapped about with several layers of a wadded quilt, and making 
use of this as a fulcrum upon which the thigh operated as a lever. 
The legs were simply pressed together, care being taken to keep the 
knees straight. 2 

After the reduction is accomplished, the patient should be laid upon 
his back in bed, but instead of rotating the limb outwards, as we have 
advised after a dislocation upon the dorsum ilii, or into the ischiatic 
notch, it should be gently rotated inwards, and the knees thus bound 
together. 

§ 4. Dislocations Upwards and Forwards upon the Pubes. 

Syn. — " Upwards and forwards on the horizontal branch of the share-bone ;" Che- 
lius. "Forwards upon the pubes ;" Pirrie. "On the bodj of the pubes, below the 
spine and transverse part of the bone ;" Skej. " Sur-pubic ;" Gerdy. "Ilio-pubic;" 
Malgaigne. 

Causes. — This accident is generally occasioned by a fall upon the foot 
when the leg is thrown backwards behind the centre of gravity; as in 
a fall from the back end of a wagon, the foot being instinctively thrown 
backwards in order to save the head; or it may happen to a person 
who, while walking, suddenly puts one foot into a hole, in consequence 
of which the pelvis advances, but the leg and upper part of the body 
incline forcibly backwards. Occasionally it has resulted from a fall 
upon the back of the pelvis, or from a severe blow received upon the 
same part. A patient was admitted under the care of Dr. Ure, into 
St. Mary's Hospital, London, with a dislocation upon the pubes, occa- 
sioned by swimming. His account of it was, that, when in the act of 
u striking out" he felt a catch in the right groin which he thought was 
cramp, and that he was able to walk after the accident, but with a 
good deal of difficulty. The examination proved that he had a dis- 
location upon the pubes, which Dr. Ure easily reduced. 3 

Pathological Anatomy. — Sir Astley Cooper dissected the hip of a 
person whose thigh had been dislocated upon the pubes for some time, 
the true nature of the accident not having been at first recognized. 
The acetabulum was partly filled by bone, and partly occupied by the 
trochanter major, both of which were much altered in their form. The 
capsular ligament was extensively torn and the ligamentum teres 
broken off completely. The head and neck of the femur had torn up 

1 Practical Surg., Amer. ed., p. 93. 

2 Brainard, North Western Med. and Surg. Journ., 1852. 

3 Medical News and Library, vol. xvi. p. 1 ; from Lond. Lancet, Nov. 7, 1857. 



670 DISLOCATIONS OF THE THIGH. 

Poupart's ligament, so as to penetrate between it and the pubes, and 
lay underneath the iliacus internus and psoas muscles; the anterior 
crural nerve was lying upon these muscles, over the neck of the femur. 
The head and neck were flattened and otherwise much changed in 
form. Upon the pubes a socket was formed for the neck of the thigh 
bone, the head being above the level of the pubes. The femoral artery 
and vein were to the inner side. This specimen is still preserved in 
St. Thomas's Hospital. (Fig. 275.) 

Fig. 275. 




1^ 

Specimen of dislocation upon the pubes, in St. Thomas's Hospital. (From Sir A. Cooper.) 

In many cases, however, the head of the bone does not rise so far 
upon the pubes, but rests either upon its upper or its anterior margin. 

Symptoms. — The thigh is shortened, abducted, flexed slightly, rarely 
extended, and rotated outwards. The trochanter major is lost, or 
nearly so, while the head of the bone may be generally felt like a 
round ball, lying upon or in front of the body of the pubes to the 
outside of the femoral artery and vein. Larrey saw a patient in whom 
the femur was placed nearly at a right angle with the body : and Physick 
once met with a dislocation upon the pubes " directly before the aceta- 
bulum," in which the limb was not at all shortened, but, on the con- 
trary, a very little lengthened. 1 Other surgeons have occasionally 
seen similar examples. 

The differential diagnosis between a fracture of the neck of the 
femur and this dislocation may be thus briefly stated. In the fracture 
there is crepitus, mobility, slight eversion easily overcome, moderate 
or no shortening, no abduction, the trochanter major rotates on a 
short radius, the head of the bone cannot be felt. In this dislocation 
there is no crepitus, the limb is immobile, the eversion is extreme 

1 Dorsey's Surgery, vol. i. p. 238, 1813. 



UPWARDS AND FORWARDS UPON THE PUBES. 



671 



and not easily overcome, there is generally more shortening, the 
thigh is abducted, the trochanter major rotates upon a longer radius, 
and the head of the bone can 
generally be distinctly felt in its 
unnatural position. 

Prognosis. — Sir Astley Cooper 
remarks that although this acci- 
dent is easy of detection, he has 
known three instances in which it 
was overlooked, and he cannot 
but regard such errors as evidence 
of great carelessness on the part 
of the surgeon who is employed. 

The reduction has generally 
been accomplished,in recent cases, 
with no great difficulty ; and when 
not reduced the patients have oc- 
casionally recovered with very 
useful limbs. 

Treatment. — From the several 
reported examples of dislocation 
upon the pubes reduced by mani- 
pulation, it would be difficult to 
draw any practical conclusions, 
since the methods have differed 
so widely from each other. I 
shall mention only three, which 
may be found in our own journals. 
One of these has already been 
mentioned in connection with the 
history of this process, as a case 
of compound dislocation, reduced 
by Dr. Ingalls, of Chelsea, Mass., 
and the two remaining examples 
were both reported by E. J. Foun- 
tain, of Davenport, Iowa. Dr. In- 
galls succeeded by carrying the 
limb into its greatest state of 
abduction and rotating the thigh 
inwards ; the replacement of the 
bone being aided also by pressing upon its head with his fingers thrust 
into the wound ; while Dr. Fountain succeeded equally in both of his 
cases, by an almost opposite mode of procedure, namely, by adducting 
the limb forcibly, rotating the thigh inwards and then flexing the 
thigh upon the body. The first of Dr. Fountain's cases occurred in 
June, 1854. The patient, an adult male, had fallen from the second 
story of a house to the ground, fracturing his lower jaw, and dislo- 
cating his left hip. The limb was a trifle shortened, and the foot 
strongly everted. The prominence of the trochanter was lessened, 
and the head of the bone could be felt upon the pubes. Assisted by 




Dislocation upwards and forwards upon the pubes. 



672 DISLOCATIONS OF THE THIGH. 

Dr. Arnold, he reduced the limb in the following manner : The patient 
was laid on the floor, and placed completely under the influence of 
chloroform. The dislocated limb was then " seized by the foot and 
knee and rotated outwards, the leg flexed and carried over the oppo- 
site knee and thigh, the heel kept well up, and the knee pressed down. 
This motion was continued by carrying the thigh over the sound one 
as high as the upper part of the middle third, the foot being kept 
firmly elevated. Then the limb was carried directly upwards by 
elevating the knee, while the foot was held firm and steady, at the 
same time making gentle oscillations by the knee, when the head of 
the bone suddenly dropped into its socket." 1 The time occupied was 
not more than thirty seconds, and the force employed was very slight. 

The second case occurred on the 31st of Oct. 1855, in the person 
of John McCarthy, an Irish laborer; the dislocation having been 
occasioned by falling with a horse, while riding. The reduction was 
effected in about twenty seconds by the same process, and without the 
aid of chloroform. 

It is probable that no one method will succeed equally well in all 
cases ; but if the head of the bone, as in the case dissected by Sir 
Astley Cooper, has not only actually surmounted the pubes, but 
pushed itself fairly into the pelvis, then the limb ought to be abducted 
in the manner practised by Ingalls, and forcibly rotated outwards, in 
order that the head may be thus lifted over the pubes; and subse- 
quently it should be flexed upon the body, adducted and brought 
down. But in this manoeuvre we ought to be careful not to continue 
the rotation outwards after the head of the femur has risen above the 
pubes, lest the head and neck should grasp, as it were, the psoas 
magnus and iliacus internus muscles, underneath which they have 
been thrust. On the contrary, it will be necessary at this point to 
rotate the thigh again gently inwards, which, by compelling the head 
to hug the front of the pubes, will enable it, while the flexion is being 
made, to slide downwards under these muscles toward the socket. If, 
however, the head of the bone has never risen upon the summit of the 
pubes, and is not actually engaged under the muscles which pass over 
it at this point, then the rotation outwards will not be necessary in 
any part of the procedure. 

Baron Larrey has reported a case of dislocation " before the hori- 
zontal portion of the pubes," which he reduced " by suddenly raising 
with his shoulder the lower extremity of the femur, while with both 
hands he depressed the head of the bone." 2 This is the same of which 
we have already spoken as being attended with the unusual pheno- 
menon of the thigh placed at a right angle with the body. 

If reduction is attempted by extension, the patient ought to be laid 
on his back upon a table, with the dislocated limb falling off slightly 
from its side. The extending band, made fast above the knee, should 
then be secured to a staple in the line of the axis of the dislocated 

1 Fountain, New York Journ. Med., Jan. 1856, p. 69 et seq. 

2 Larrey, Lond. Med.-Chir. Rev., Dec. 1820, p. 500 ; vol. i. first ser., from Bullet, 
de la Fac. de. Med., No. 1. 



ANOMALOUS DISLOCATIONS. 673 

thigh, and of course below the table; while the counter-extending 
band, crossing under the perineum, should be made fast in the same 
line, above the level of the table, and beyond the head of the patient. 
When extension is commenced, and the head of the femur has 
begun to move, the reduction may sometimes be facilitated by lifting 

Fi«. 277. 




Reduction of dislocation upon the pubes, by extension. 

the upper part of the thigh with a jack towel or a band passed under 
the thigh and over the neck of the surgeon, as we have recommended 
in both of the backward dislocations. 



§ 5. Anomalous Dislocations, or Dislocations which do not properly 
belong to either of the four principal divisions before described. 1 

1. Dislocations directly Upwards. 

Syn. — " Sus-Cotyloidiennes ;" Malgaigne. " Sixth dislocation ;" Mutter. 

Malgaigne affirms that the head, in this dislocation, is situated 
external to the anterior inferior spinous process, and about one inch 
below the anterior superior spinous process. But this position is not 
uniform. It may be found in front of the inferior process, or above 
as well as behind, or external to it. 

The symptoms which characterize this accident are shortening of 
the limb, slight abduction and extension, with extreme eversion or 
rotation outwards. The eversion of the toes together with the slight 

1 Malgaigne, Traite" des Frac. et des Lux., torn. ii. p. 869 et seq. Samuel Cooper, 
First Lines, vol. ii. p. 391. Pirrie's Surg., Amer. ed., 1852, p. 275. Skey's Surg., 
Amer. ed., 1851, p. 110 et seq. Gibson's Surg., sixth Amer. ed., vol. i. p. 386. Guy's 
Hospital Reports, vol. i. 1836, pp. 79 and 97 ; vol. iii. 1838, p. 163. London Lancet, 
Lond ed., vol. i. 1848, p. 184; vol. ii., 1840, p. 281 ; vol. i., 1845, p. 412 ; vol. ii. p. 
159. London Med. Graz., vol. xix. pp. 657 and 659 ; vol. x. p. 19 ; vol. xxxiii. p. 
404. Med.-Chir. Trans., vol. xx. p. 112. Lente's paper on "Anomalous Dislocations 
of the Hip-Joint," in New York Journ. Med. for Nov. 1850, p. 314 et. seq. Philadelphia 
Med. Examiner, No. 51. Amer. Journ. Med. Sci., vol. xvi. p. 14. New York Med. 
and Phys. Journ., 1826, vol. v. p. 597. New York Journ. Med., Jan., 1860, Dr. Shrady's 
case. 



674 DISLOCATIONS OF THE THIGH. 

amount of shortening which has in general been observed, has led 
several times to the supposition that it was a fracture of the neck of 
the femur ; but the rigidity, and the position of the trochanter and 
head will usually render the diagnosis clear. 

Cummins reports a case which occurred in the practice of Gibson, 
of New Lanark, where the head of the bone was believed to be situated 
just below the anterior superior spinous process, and inwards toward 
the pubes. The limb was shortened fully three inches; the toes 
everted ; adduction and abduction were exceedingly painful and diffi- 
cult, but flexion was more easily performed. The head of the bone 
could be felt in its new position, especially when the thigh was moved. 
At first it was supposed to be a fracture, but this error having been 
corrected, the surgeons proceeded to attempt reduction on the eleventh 
day. Extension was made by pulleys, and when the head of the bone 
had descended to the margin of the cavity, Mr. Gibson lifted the upper 
end of the femur by means of a towel, at the same moment pressing 
the knee toward the opposite thigh, and forcibly rotating the limb 
inwards ; by which means the reduction was accomplished. 1 

Lente has seen the head of the femur in the same position as in the 
case reported by Cummins, not as a primitive dislocation, but conse- 
quent upon an attempt to reduce a dislocation into the ischiatic notch. 
The shortening was about two inches ; the limb very much rotated 
outwards ; the rotundity of the affected hip greater than that of the 
other, and the trochanter major one inch further removed from the 
anterior superior spinous process. The head of the bone could be 
felt distinctly in its new position. 

The reduction was effected finally with pulleys, by the aid of chlo- 
roform, and by rotation of the limb in various direction. 2 

Morgan also reports a case in which the head of the femur was 
above the acetabulum, and a little to the outside of the ilio-pectineal 
eminence. 3 

In a majority of cases these dislocations have been reduced by 
manipulation alone, or by manipulation aided by pressure. The limb 
should be seized in the usual manner, at the knee and ankle, car- 
ried up toward the face, abducted, then rotated inwards, gently ad- 
ducted, and finally brought down again to the bed. At the moment 
when the rotation and adduction commence, the head of the bone 
should be pressed toward the socket by the hands, and, if necessary, 
lifted a little over the margin of the acetabulum, by moderate exten- 
sion at a right angle with the body. 

2. Dislocations Downwards and Backwards upon the Posterior Part of the 
Body of the Ischium, between its Tuberosity and its Spine. 

James C , set. 35, was admitted to the Pennsylvania Hospital on 

the 23d of January, 1835, under the care of Dr. Hewson. The patient, 
a muscular man, had been crushed under a falling roof, and, as he 

1 Cummins, Guy's Hospital Reports, vol. iii. p. 163, 1838. 

2 Lente, New York Journ. of Med., Nov. 1850, p. 314. 

3 Pirrie's Surgery, p. 276. See also Phil. Med. Exam., No. 51, Mutter's paper. 



ANOMALOUS DISLOCATIONS. 675 

thought, with his right thigh separated from his body. When received 
into the hospital, one hour after the accident, the right thigh was flexed 
upon the pelvis, and rested upon the left; the right leg was also flexed 
upon the thigh; the knee was below its fellow, the toes turned in- 
wards, and the whole limb shortened at least one inch. The head of 
the bone could be felt distinctly resting upon that portion of the 
ischium which lies between the acetabulum, the tuberosity of the 
ischium and the spine. 

On the following day, the muscles of the patient having been suffi- 
ciently relaxed by suitable means, the pulleys were applied ; but, after 
a second attempt, some of the bands having given way suddenly, the 
pulleys were removed, when it was found that the reduction had been 
accomplished, although neither the patient nor his attendants had 
noticed the return of the bone to its socket. For several days there 
was entire loss of sensibility and motion in the leg, owing probably to 
the pressure which had been made upon the sciatic nerve; but these 
symptoms gradually disappeared, and at the time when the case was 
reported, about two months after the accident, he was walking with 
crutches. 

Dr. Kirkbride, who has reported this unusual case of dislocation, 
doubts whether the extension was necessary to the reduction, as the 
head of the bone was brought very near the margin of the acetabulum 
by lifting the thigh with a towel, and it probably afterwards entered 
the socket so soon as the extension was relaxed. 1 

Malgaigne has referred to several similar examples. 



3. Dislocations Downwards and Backwards into the lesser or lower Ischi- 

atic Notch. 

Syn. — " Behind tuber ischii ;" Gibson, S. Cooper. "Fifth, dislocation ;" Gibson. 

September 7, 1821, Charles Lowell, of Lubec, Mass., was riding a 
spirited horse, when the animal, being restive, suddenly reared and fell 
back on his rider, in such a manner as that the weight of the horse 
was received on the inside of the left thigh ; Mr. Lowell having fallen 
on his back, a little inclined to the left side. The surgeon, who was 
immediately called, recognized it as a dislocation, and thought he had 
succeeded in reducing it; but a day or two later it was seen by a 
second surgeon, who declared that it was still out of place, and re- 
peated the attempt at reduction, but without success, as the result 
proved. 

In December of the same year Mr. Lowell called upon John C. 
Warren, of Boston, who was now able to determine, easily, as he 
affirms, the precise character of the accident. The limb was elongated, 
contracted, and the head could be felt in its unnatural position. By 
advice of Dr. Warren, he was taken to the Massachusetts General 
Hospital, and a persevering attempt was there made to reduce the 

1 Kirkbride, Arner. Journ, of Med. Sci., vol. xvi. p. 13. 



676 DISLOCATIONS OF THE THIGH. 

bone, but with no better success than bad attended the efforts pre- 
viously made. 1 

Mr. Keate has reported a case produced in a very similar way by 
a horse having fallen backwards with the rider into a deep and narrow 
ditch; but the position of the limb was somewhat extraordinary, con- 
sidering that it was a dislocation backwards, the whole limb being 
very much abducted and the toes being turned outwards, as if the head 
of the bone was in front of the tuber ischii, rather than behind it. 
The thigh and leg were much flexed, and the whole limb was short- 
ened from three to three inches and a half. The head of the femur 
could be distinctly felt "inferior to the ischiatic notch, and on a level 
with the tuberosity of the ischium." In the first attempt at reduction 
the head of the bone was thrown into the foramen ovale, from which 
it was, however, after one or two more attempts by extension, and by 
lifting with a jack-towel, restored to the socket. Mr. Keate believes 
that the dislocation was originally into the foramen ovale, but that in 
the struggles made by the patient to extricate himself, it was thrown 
backwards into the position in which he found it. 2 

Mr. Wormald has reported a primitive accident of the same kind, 
occasioned by jumping from a third story window. The patient died 
soon after, and at the autopsy the head of the femur was found under 
the outer edge of the glutaeus maximus, projecting through the torn 
capsule opposite the upper part of the tuber ischii. The shaft of the 
femur lay across the pubes, and the limb was considerably shortened 
and turned inwards. 3 



4. Dislocations Directly Downivards. 
Syn. — " Sous-cotylo'idiennes ;" Malgaigne. 

The following is one of several similar examples now upon record : — 
A man set. 50, was admitted into the London Hospital under the 
care of Mr. Luke. A dislocation of the left femur was easily diagnos- 
ticated, but the symptoms were peculiar, inasmuch as the limb was 
lengthened one inch, without either inversion or eversion; yet the 
head of the bone could be easily felt, and was thought to be in the 
ischiatic notch. By manipular movements reduction was easily effected 
about an hour after the accident. The man subsequently died from 
the effects of broken ribs. At the autopsy, Mr. Forbes, the house- 
surgeon, before dissecting the parts, again dislocated the bone. This 
was done with ease, and it was clear that the original form of disloca- 
tion had been reproduced, as the bone could not be made to assume 
any other position. The head of the bone proved to be displaced 
neither into the ischiatic notch nor the thyroid hole, but midway be- 
tween the two, immediately beneath the lower border of the acetabulum. 
The gemellus inferior and the quadratus femoris had been torn, the 

1 New York Med. and Phys. Journ., vol. v. p. 597, 1826. Letter to the Hon. Isaac 
Parker, &c, by John C. Warren : 1826. North Amer. Med. Journ., vol. iii. p. 169. 
* Amer. Journ. Med. Sci., vol. xvi. p. 226, 1835. From Loud. Med. Gaz., vol. x. p. 19. 
Wormald, London Med. Gaz., 1S36. 



ANOMALOUS DISLOCATIONS. 677 

ligaraentum teres had been wholly detached, and there was a laceration 
in the lower part of the capsular ligament. 1 

Dr. Blackman, of Cincinnati, informs me that in Jan. 1859, he re- 
duced a sub-cotyloid, incomplete dislocation, in a man set. 70, by 
manipulation, Dr. Judkins lifting the thigh upwards and outwards by 
means of a towel, while Dr. Blackman first flexed and then abducted 
the limb. 

5. Dislocations Forwards into the Perineum. 

Syn. — "Perineales ;" Malgaigne. "Luxation surla"branche ascendante de l'ischion ;" 
D'Amblard. " Inwards on the ramus of the os pubis ;" Skey. 

D'Amblard published an example of this accident in 1821, occa- 
sioned by a violent muscular exertion made by the patient in an effort 
to spring into his carriage, the symptoms attending which did not 
differ materially from those which were found to be present in the 
three following examples, except that in the first case the toes were 
turned slightly inwards, while in each of the other cases they were 
turned outwards. 2 

Mr. E , set. 35, a calker by occupation. The injury was re- 
ceived while at work under the bottom of a canal boat, July 20, 1831, 
the boat being raised upon props three and a half feet long. The 
patient was standing very much bent forwards, with his feet far apart, 
between which lay a piece of round timber one foot in diameter, when 
the props gave way, letting the whole weight of the boat upon him- 
self and his companions. One of the workmen was killed outright. 
On extricating Mr. E. from his situation, the left leg and thigh were 
found extended at a right angle with the body, the toes turned slightly 
inwards, the natural form of the nates was lost, and the head of the 
femur could be felt distinctly moving, when the limb was rotated, in 
the perineum, behind the scrotum, and near the bulb of the urethra. 

For the purpose of reduction, the patient was laid on his back upon 
a table, and the pelvis made fast by a muslin band. Extension, ac- 
companied with moderate rotation, was then made in a direction out- 
wards and downwards, bringing the head of the bone over the ascend- 
ing ramus of the ischium, beyond which it was lying, into the foramen 
thyroideum ; and from this position the bone was replaced in the 
acetabulum, by carrying the dislocated limb forcibly across the oppo- 
site one. The patient soon recovered the use of the joint. 3 

J. B., an Irishman, aet. 40, on entering the. St. Louis Hospital, gave 
the following account of his accident, which had occurred six hours, 
previously. He was engaged in excavating earth, and having under- 
mined a bank, it unexpectedly fell upon his back while he was stand- 
ing in a bent position, with his thighs stretched widely apart. The 
weight crushed him to the earth, breaking both bones of his right leg,. 
the radius of the same side, and dislocating the left hip into the peri- 

1 Luke, Med. News and Library, vol. xvi. p. 34, March, 1858; from Med. Times and 
Gaz., Jan. 2, 1858. 

2 Malgaigne, op. cit., torn. ii. p. 876. 

3 W. Parker, New York Med. Gaz., 1841 ; N. Y. Journ. Med., March, 1852, p. 188 



678 DISLOCATIONS OF THE THIGH. 

neum. The thigh presented a peculiar appearance, being placed quite 
at a right angle with the body, but somewhat inclined forwards. The 
part of the hip naturally occupied by the trochanter major presented 
a depression deep enough to receive the clenched fist ; while the head 
of the bone could be both seen and felt projecting beneath the skin of 
the raphe in the perineum. Eotation of the limb, which was difficult 
and excessively painful, rendered the position of the head still more 
manifest. The patient had also retention of urine, occasioned proba- 
bly by the pressure of the femur upon the urethra. Having dressed 
the fractures, Dr. Pope placed the patient under the full influence of 
chloroform, and then proceeded to reduce the dislocated thigh ; for 
which purpose "two loops were applied, interlocking each other in 
the groin, and using the leg as a lever, extension, by means of the 
pulleys, was made transversely to the axis of the body. A steady 
force was kept up for a short time, and the thigh-bone glided into its 
socket with a snap that was heard by every attendant and patient in 
the large ward." 1 

A man, set. 22, was admitted to the Toronto Hospital, under the 
care of Dr. E. W. Hodder, Jan. 15, 1855, having been injured by the 
fall of a bank of earth an hour before. The head of the right femur 
was found under the arch of the pubes, the neck resting upon the as- 
cending ramus. The thigh formed nearly a right angle with the 
body ; it was also strongly abducted, and the toes were slightly everted. 
On the following day, the patient being placed under the influence of 
chloroform, extension and counter-extension were employed in the 
direction of the axis of the femur, that is, nearly at right angles with 
the body, while, at the same moment, the upper portion of the femur 
was lifted by a round towel. By this manoeuvre the head of the bone 
was carried into the foramen thyroideum. The force was now applied 
in a direction " more upwards and outwards ; the ankle held by the 
assistant was drawn under the other and at the same time rotated." 
In a few minutes the complete reduction was accomplished. His re- 
covery has been steady, and three weeks later he was discharged being 
able to walk very well with the aid of a cane. 2 

§ 6. Ancient Dislocations of the Femur. 

Says Sir Astley Cooper: "I am of opinion that three months after 
the accident, for the shoulder, and eight weeks for the hip may be 
fixed as the period at which it "would be imprudent to attempt to make 
the reduction, except in persons of extremely relaxed fibre, or of ad- 
vanced age. At the same time, I am fully aware that dislocations 
have been reduced at a more distant period than that which I have 
mentioned ; but in many instances the reduction has been attended 
with the evil results which I have just been deprecating." A remark 
which later surgeons do not seem always to have correctly understood, 

1 Pope, St. Louis Med. and Surg. Journ., July, 1850; N. Y. Journ. Med., March, 
1852, p. 198. 
2 Hodder, British Amer. Journ., March, 1861. 



ANCIENT DISLOCATIONS OF THE FEMUR. 679 

or which, if thej have understood, they have not correctly represented ; 
since it has many times been affirmed of this distinguished surgeon, 
that he regarded reduction of the hip as impossible after eight weeks, 
and they have proceeded to cite examples which would prove that he 
was in error. But long before Sir Astley's day, Gockel mentioned a 
case of reduction of the femur after six months, and Guillaume de 
Salicet declared that he had reduced a similar dislocation after one 
year, 1 and Sir Astley says, that he is " fully aware" of the existence of 
such facts ; yet with a knowledge of what has so frequently followed 
these attempts, he would not recommend the trial after eight weeks, 
except under the circumstances by him stated ; and notwithstanding 
the number of these reported successes has been considerably increased 
in our day, we suspect that Sir Astley's rule will continue to govern 
experienced and discreet surgeons. Two examples which have re- 
cently been published of successful reduction after six months by 
manipulation, would encourage a hope that the period might be greatly 
extended, were it not that manipulation also has already failed many 
times in the case of ancient luxations, and that the attempt has some- 
times been followed with disastrous results, even in recent cases. 

The following are the two examples of reduction by manipulation 
after the lapse of six months : — 

On the 21st of March, 1856, a man presented himself at the Com- 
mercial Hospital, Cincinnati, with a dislocation of the femur upon the 
dorsum ilii, of six months' standing. The limb was shortened two 
inches. Dr. Blackman, under whose care he was admitted, adminis- 
tered chloroform, and by manipulating after the method described by 
Dr. Eeid, the reduction was accomplished. 2 

In a letter addressed to me by Dr. Blackman, and dated April 21st, 
1859, he informs me that this patient presented himself again before 
the class about six months since, and the restoration of the functions 
of the limb was found to be complete. 

The second example occurred in the practice of Martial Dupierris, 
of Havana, Cuba. A Chinese boy named A-sin, aged about sixteen 
years, arrived at Havana on the fourth of June, 1856, suffering under 
a severe illness, which confined him for a month or more to his bed, 
and the existence of the dislocation was not discovered until he had 
sufficiently recovered to rise upon his feet. It was then ascertained 
that he had a dislocation of the left femur upon the dorsum ilii. Upon 
inquiry, Dr. Dupierris learned that the accident had occurred be- 
fore leaving China, a period of more than six months. The boy was 
still feeble, the limb somewhat emaciated, and instead of being rigid 
from muscular contraction, all the muscles "were in a flaccid condi- 
tion, except the great gluteal, which was painful to the touch." Deem- 
ing the use of anaesthetics improper, on account of the boy's feeble 
condition, these agents were not employed. Dr. Dupierris describes 
the method of reduction as follows : " The body being held by two 

1 Malgaigne, op. cit., torn. ii. p. 185 ; from Gallicinium Medic o-practicum, Ulm, 1700, 
p. 288. 

2 Blackman, Ohio Med. and Surg. Journ., vol. viii. p. 522. 



680 DISLOCATIONS OF THE THIGH. 

assistants by means of two bands, one of which passed beneath the 
perineum, and the other under the axillae, traction was made upon the 
limb by two strong and intelligent assistants. The movement of the 
head of the bone, resulting from this manoeuvre, was very limited, 
even when the force was much increased ; and the excruciating pain, 
which the patient referred to the iliac region, compelled us for the 
moment to desist. 

" The following day, the patient having obtained a tolerable night's 
rest by means of a narcotic potion, I concluded to attempt the reduc- 
tion by flexion, believing that I could thus better prevent any accident 
which the necessary force might produce ; the operator, in adopting 
this method, having it in his power to follow the head of the bone by 
pressure upon it with the hand, aiding its movement in the proper 
direction, or correcting any deviation that may occur. The emaciated 
condition of the boy was eminently favorable for such a procedure. 

"The patient being placed upon his back, and the trunk of the body 
made steady by assistants, with the left hand I grasped the upper 
part of the leg, placed the right hand upon the head of the bone in the 
iliac fossa, and then proceeded to flex the leg upon the thigh, and the 
thigh upon the pelvis. By this movement the great gluteal muscle 
was relaxed, and the head of the bone advanced, while with the right 
hand I directed the latter toward the cotyloid cavity. As soon as I 
judged the head to be immediately above the centre of the socket, I 
extended the leg, the thigh remaining flexed at a right angle ; and 
then using the limb as a lever, I rotated it from within outwards, and 
at the same time extended it by making a movement of circumduction 
in a similar direction. When by these procedures the limb was 
brought near to its opposite fellow, a snap audible to the assistants, 
and of a deeper character than is ordinarily observed in the reduction 
of recent dislocations, indicated the return of the head of the bone to 
its natural position ; a fact which was further substantiated by the 
establishment of the original length and form of the member and the 
subsidence of the pain. 

"The after treatment consisted in placing a pad between the knees, 
and another between the internal malleoli, and confining the limbs 
together by two bands, one above the knees, and the other around the 
lower part of the legs. But in spite of these precautions to prevent 
redisplacement, the next morning I found that the dislocation had 
been reproduced. It was again reduced, but for three successive days 
there was a redisplacement. After this, however, the head of the bone 
kept its place ; passive motion was daily employed, and all suffering 
ceased. After twenty days of rest, and 1 a liberal use of the lactate of 
iron, the patient was allowed to get up ; and, being provided with a 
pair of crutches, upon which he exercised himself daily, improved 
very rapidly. The muscles gradually recovered their bulk and vigor; 
and at the end of forty-eight days he was enabled to walk without 
crutches, although with some fear of falling. About the middle of 
August, he was put to work in a cigar manufactory, and has continued 
well ever since." 

In the comparison of the relative value and hazards of the different 



PARTIAL DISLOCATIONS OF THE FEMUR. 681 

modes of reduction I have cited several examples of fracture of the 
neck of the femur in the attempt to reduce ancient dislocations. 

§ 7. Partial Dislocations of the Femur. 

Malgaigne declares that certain experiments made upon the cadaver 
led him, at one time, to the conclusion that all primitive luxations of 
the femur were incomplete, and that the old complete luxations found 
in autopsies, had become so consecutively. Later observations have 
taught him to correct this error, yet he still finds " incomplete back- 
ward luxations quite common, and incomplete dislocations in all the 
other directions much more common." 

I have more than once found occasion to call in question the 
accuracy of Malgaigne's views in relation to partial dislocations, the 
relative frequency of which he seems constantly disposed to greatly 
exaggerate. We cannot see the propriety of calling those cases par- 
tial dislocations, in Avhich the head of the bone has fairly left the coty- 
loid cavity, and mounted upon its margin ; even if it remains in this 
position without tearing the capsule ; since the articular surfaces are 
now as completely separated as if the capsule had given way, and the 
head of the bone had escaped through the laceration. It is in fact a 
complete luxation. But I doubt very much whether the head of the 
bone ever rests upon the margin of the acetabulum without tearing 
the capsule, unless it has previously undergone certain pathological 
changes, such as I have already described ; at least I cannot hesitate 
to reject all those examples in which the head of the femur is sup- 
posed to rest upon the upper or outer margin of the acetabulum ; and 
if I permit myself to speak of incomplete dislocations at all in this 
connection, I shall reserve the term for those rare cases in which the 
head of the femur becomes engaged in the cotyloid notch, after break- 
ing down the fibrous band which, in the natural state, is continuous 
with the rim of the acetabulum. 

Of this form of dislocation, I think I have met with two examples ; 
one of which was in the person of the boy Lower, already mentioned, 
whose thigh was reduced accidentally by his father ; and the other 
occurred in a boy fifteen years of age, residing at that time in Kutland, 
Yermont. He was brought to me on the 28th of May, 1842, by Dr. 
Haynes, of Eutland, at which time the dislocation had existed five 
years. His account of himself was that in walking upon a slippery 
floor, his left leg slid outwards and backwards in such a manner as 
that when he fell it was fairly doubled under his back. On the tenth 
day following the accident, he began to walk with some help, and he 
has continued to walk ever since, but with a manifest halt. Three 
months after the injury was received, it was first seen by several 
surgeons, who pronounced it a dislocation, and attempted reduction, 
without mechanical aid, but were unsuccessful. 

When the young man was brought to me, the limb was neither 
lengthened nor shortened, but the thigh was forcibly abducted and 
rotated outwards. It could not be flexed nor greatly extended. The- 
44 



682 DISLOCATIONS OF THE THIGH. 

head of the femur could be distinctly felt, as it lay anterior to the 
socket, but not sufficiently far forwards to rest upon the foramen 
ovale. 

J. C. Warren, of Boston, has reported a similar example in a child 
six years old, who was brought, April 21, 1841, to the Massachusetts 
General Hospital. Dr. Hale, who saw the lad at the end of two weeks, 
thought it a dislocation, but it had been treated by another surgeon 
as a case of hip-disease. The dislocation had now existed eight or 
ten weeks. The limb was a little lengthened, abducted, turned out- 
wards, and advanced in front of the body, with very slight motion of 
either flexion or extension, and almost no tenderness about the joint. 
Dr. Warren, also, was able to feel indistinctly the head of the bone 
"immediately external to, and in contact with, the insertion of the 
triceps and gracilis muscles." 

An attempt was made by manual extension and manipulation to 
accomplish the reduction, but without success. 1 

It is probable that both the above cases which I have described 
at length, were examples of partial dislocation ; yet I cannot conceal 
from others a doubt which I actually entertain whether they were 
not, after all, only examples of hip-joint disease, arrested after having 
wrought certain slight pathological changes in the joint and the tis- 
sues adjacent. If, however, they were not examples of incomplete 
dislocations of the hip-joint, then I question whether any such cases 
have ever occurred. 



§ 8. coxo-eemoral dislocations, complicated with fracture of the 

Femur. 

Such complications are exceedingly rare, but it will not do to deny 
their possibility ; although in some of the cases reported, the testimony 
is so incomplete as to leave a- doubt whether the surgeons have not 
erred in their diagnosis. 

James Douglas has reported a case of dislocation upon the pubes, 
complicated with a fracture of the neck of the femur, the actual con- 
dition of which was verified by an autopsy ; the patient having died 
twelve years after the injury was received. The head of the femur 
still remained above the pubes, and was in no way connected with its 
neck or shaft. The upper end of the femur projected in the groin, 
lying upon the inside of the femoral artery and vein. Many other 
curious pathological changes had also occurred. 3 

The well-authenticated examples of reduction of the dislocation, 
where the femur was broken also, are still more rare ; and several of 
the recorded examples which my researches have discovered, need 
additional confirmation. 

John Bloxham, of Newport, in the Isle of Wight, claims to have 
reduced a dislocation of the femur on the pubes, which was accom- 

1 Warren, Bost. Med. and Surg. Journ., vol. xxiv. p. 220. 

2 Amer. Journ. Med. Sci., vol. xxxiii. p. 455, from Loud, and Edin. Month.. Journ. 
of Med. Sci., Dec. 1843. 



COXO-FEMORAL DISLOCATIONS WITH FRACTURE. 683 

parried with a fracture of the thigh a little above its middle. The 
following is the account of this interesting case which we find in the 
London Medico- Chirurgical Review, copied from the Medical Gazette of 
Aug. 21th, 1833. We regret that we are unable to see the account as 
published in the Gazette, which might supply some circumstances 
important to a full appreciation of the case : — 

On the seventh or eighth day after the accident, " the patient was 
laid upon his back on the bed and kept in that position by means of 
a sheet passed across the pelvis, and fastened to the bedstead ; another 
sheet was also passed over the left groin, and secured in a similar 
manner. The dislocated and fractured limb was then inclosed in 
splints, one of which extended up the back of the thigh as far as the 
tuberosity of the ischium. Pulleys, which were secured to a staple in 
the ceiling, placed at the distance of a foot to the right of a point 
vertical to the patient's navel, were then attached to a bandage fastened 
round the splints as high up as possible. 

" The foot was raised with the knee extended, so as to bring the 
limb nearly to a right angle with the line of the tackle, when, by 
drawing gradually on the cord, in the course of about ten or fifteen 
minutes the head of the bone was rendered movable, and was brought 
considerably more forward. I then began to press on the head of the 
bone, so as to push it downwards, whilst the pulleys held it partially 
disengaged from the pelvis. In a few minutes the head of the bone 
passed over the ridge of the os pubis, and I then directed the foot to 
be raised a little higher, which, by putting the gluteii muscles more 
upon the stretch, was calculated to render them more efficient in 
drawing the bone into its proper place. By this manoeuvre, the head 
of the bone was drawn backwards, and on the foot being more elevat- 
ed and the cord slackened, it continued to recede from my fingers till 
the trochanter major made its appearance in the natural situation, and 
the reduction was found to be perfectly complete. 

" Lest the head of the bone should slip backwards on the dorsum 
ilii, I directed an assistant to apply firm pressure during the latter 
part of the process, above and behind the acetabulum, 

" The apparatus was then removed, the thigh bound up in short 
splints, and the patient laid upon a double inclined plane. No symp- 
toms of inflammation appeared afterwards about the joint. Passive 
motion was employed at the end of a week, and occasionally repeated 
during the whole reparatory process." 1 

Without intending to question the accuracy of the statements in 
this case, which, in the main, seem to bear the marks of credibility, 
we must express our surprise that so little difficulty was experienced 
in the reduction if the femur was actually broken, no more, indeed, 
than is usually experienced when the bone is not broken ; and that 
Mr. Bloxham was able to employ safely passive motion at the end of 
a week. 

Charles Thornhill relates, in the London Medical Gazette for July, 
1836, a case of fracture of the femur through its upper third, in a 

1 Lond. Med.-Chir. Rev., vol. xix. p. 420, Oct. 1833. 



684 DISLOCATIONS OF THE THIGH. 

man get. 40, with dislocation into the ischiatic notch ; which disloca- 
tion, he assures us, was reduced at the end of six weeks. But it is 
much more probable that, instead of reducing a dislocation, he re- 
fractured the bone. During more than one hour and a half, aided by 
pulleys, tractions and manipulations were made in almost every di- 
rection. 

The upper part of the thigh was lifted with all the strength of one 
man by means of a jack towel ; it was violently rotated, adducted, 
and abducted. Both the perineal and the knee band gave way, from 
the excess of the force employed ; and, finally, the head of the femur 
resumed its place with an audible crash. After which the "limb was 
of nearly equal length with the other ;" but there remained an " im- 
mense deposit" around the acetabulum. 1 

Malgaigne says that M. Eteve found a poor fellow with a disloca- 
tion of his left thigh backwards, a fracture near its middle, a penetrat- 
ing wound of the knee, and a fracture of the fibula in the same leg. 
Without delay he proceeded to reduce the dislocation by directing two 
assistants to support the body, three to support the leg, and two more 
to make extension from a towel tied not very tightly around the 
thigh above the fracture. The leg was then extended upon the thigh 
and the thigh flexed upon the pelvis until it was at a right angle with 
the body ; and after a gradual extension had been made in this direc- 
tion, M. Eteve pushed with all his strength the head of the bone into 
its socket. Of which case Malgaigne justly remarks, that the "exten- 
sion" practised by the surgeon was only imaginary. 2 If the reduction 
was accomplished at all, it was by manipulation and pressure. 

Finally, Markoe relates in the paper to which we have already 
several times made allusion, the case of a boy set. 8, who was admit- 
ted into the New York City Hospital on the 29th of June, 1853, with 
a compound fracture of the right thigh, a simple fracture of the left, 
and a dislocation of the head of the right femur upwards and back- 
wards upon the dorsum ilii. 

When placed upon the bed, the right limb lay obliquely across the 
abdomen of the boy, with the foot resting against the axilla of the 
left side. " The house-surgeOn, to whose care the case fell on admis- 
sion, took the injured limb in his hands and very carefully carried it 
over the abdomen to the right side, and then adducted it and brought 
it down toward the straight position," during which procedure the 
head of the bone is supposed to have resumed its place in the socket. 3 

Such is the account furnished of the symptoms and treatment of 
this extraordinary case ; too meagre certainly to entitle it to much 
confidence, or to permit us to draw from it any practical inferences. 
\Ye are not even informed what was the name of the young man who 
alone saw and treated the case, nor what was his responsibility as a 
surgeon. 

I have been unable to find any other examples of fracture of the 
femur complicated with dislocation; and, rejecting at least Mr. Thorn- 

1 Amer. Journ. Med. Sci., vol. xxv. p. 218. 

2 Malgaigne, op. cit., tom. ii. p. 206 ; from Gazette Med., 1838, p. 757. 

3 New York Journ. Med., Jan. 1855, p. 30. 



VOLUNTARY DISLOCATIONS OF THE FEMUR. 685 

hill's case as altogether incredible, the proper conclusion would be, 
that redaction is sometimes possible in recent cases, if the surgeon 
will resort promptly, before swelling and muscular contractions have 
taken place, to manipulation combined with pressure upon the head 
of the bone. Indeed, it is probable that pressure alone is the means 
upon which the success will finally depend. Eichet says that he has 
several times dislocated the femur in the cadaver ; and then, having 
sawn off the head so as to represent a fracture, he has always been 
able to push the head of the bone easily into its socket. 1 By seizing 
the moment then when the patient is laboring under the shock, or by 
placing him completely under the influence of an anaesthetic, no re- 
sistance will be offered by the muscles any more than in the cadaver, 
and the reduction may, perhaps, be easily effected. 

I have no confidence that anything can be accomplished by exten- 
sion ; nor do I think it will be best to wait until the femur has united, 
since such delay will probably render the reduction impossible. 

§ 9. Voluntary Dislocations of the Femur. 

Examples in which persons, having suffered no disease of the hip- 
joint, have been able voluntarily to dislocate the femur, have, from 
time to time, been recorded, but I am not aware that any dissections 
have ever been made in these cases. I shall, therefore, not attempt 
any explanation of the facts, but simply record them as matters of 
curious interest, and for the purpose of inducing others to make of 
them a subject of investigation. 

Sir Astley Cooper mentions the case of a man, who could throw 
out the head of the thigh bone at pleasure, and reduce it with equal 
facility. A similar case is alluded to by Samuel Cooper, in his First 
Lines. Gibson mentions a case reported by Dr. Lewis, of North 
Carolina. 2 The following case was reported to me in 1865, by John 
M. Forrest, M. D., of Portland, Maine, to whom the man presented 
himself as a " substitute," while Dr. Forrest was in the service of the 
U. S. Army. The application was rejected. 

"¥m. Gr. Gliddon, est. 37, farmer, says that he has been able to dis- 
locate and replace the femur at the left hip-joint since he was a boy. 
It is not the result of any inj ury or disease so far as he knows. He is in 
good health, and his muscular development is complete. He accom- 
plishes the dislocation by throwing the weight of his body upon the 
left leg, and then contracting certain muscles about the hip. The ■ 
reduction is generally more difficult than the dislocation, sometimes 
requiring the aid of his hand. When the head of the bone is out 
there is a marked projection above and behind the trochanter major, 
apparently caused by the pressure of the head in this situation ; the 
limb is very slightly if at all inverted ; while out of place it causes 
pain ; and after a few repetitions the pain becomes so great as to com- 
pel him to desist. The limb was not measured while it was dislo- 
cated. When the limb is in position he does not walk lame." 

1 New York Journ. Med., March, 1854, p. 293: from Bullet, de Ther. 

2 Gibson's Surgery, vol. i. p. 367, 6th ed. 



686 DISLOCATIONS OF THE PATELLA. 

The following is the only case which has come under my personal 
observation: Dr. AYm. Gr. S., aet. 24, received an injury on the out- 
side of the right knee, in Feb., 1862, from the kick of a horse. There 
was no apparent injury of the hip. On the fourteenth day after the 
accident he rode forty miles on horseback, which was followed by some 
stiffness in the right hip. Two weeks later, in mounting his horse, he 
felt something slip in the hip-joint. From that day until this, a period 
of four years, he has been able to reproduce the same slipping volun- 
tarily, and which phemomenon I recognize as a dislocation upwards 
and backwards. I have examined him more than once, and he has 
dislocated and reduced the dislocation in my presence repeatedly. 
Planting his right foot firmly upon the floor a little in advance of the 
left, with his toes turned out, he throws his weight upon the right 
leg by carrying his pelvis well over to the right, and then contracts 
powerfully the gluteal muscles. Instantly the head leaves the socket, 
and seems to mount upon the dorsum ; the trochanter major becomes 
rotated inwards, causing a slight inward rotation of the leg and foot. 
He can do the same when lying on his back, but not with the same 
ease. Reduction is accomplished without change of position, but 
by what precise manoeuvre I have not determined. The reduction is 
more quiet, and less sudden apparently than the dislocation. Both 
manoeuvres are accompanied with some pain. He is not lame, nor 
does the dislocation take place without his volition. 



CHAPTEE XVII. 

DISLOCATIONS OF THE PATELLA. 

§ 1. Dislocations of the Patella Outwards. 

Causes. — In the majority of cases it has been occasioned by muscu- 
lar action ; and especially is this liable to occur in persons who are 
knock-kneed, or whose external condyles have not the usual promi- 
nence anteriorly. It may be caused by suddenly twisting the thigh 
inwards while the weight of the body rests upon the foot, and the leg 
is thus kept turned outwards ; or by falling with the knee turned 
inwards and the foot outwards. Occasionally it is the result of a blow 
received upon the inside, or upon the front and inner margin of the 
patella. In some persons there seems to exist a preternatural laxity 
of the ligamentum patellae or of the tendon of the quadriceps extensor 
which exposes the subject to this accident from very trifling causes. 
Fergusson says he has known it to be occasioned by a child's stepping 
upon the knee of a person lying in bed : and Skey says he has seen 
two cases which occurred spontaneously during sleep. B. Cooper 
has seen a young lady who frequently dislocated her patella outwards 
by merely striking her toe against the carpet, or in dancing. Boyer, 
Sir Astley Cooper, and others, mention similar examples. 



DISLOCATIONS OF THE PATELLA OUTWARDS. 



687 



Pathological Anatomy. — Most frequently the dislocation is only par- 
tial, the inner half of the patella resting upon the articular surface of 
the outer condyle ; and in consequence of the peculiar obliquity of 
these surfaces, together with the action of the vasti and rectus femoris, 
the outer margin of the patella becomes tilted forwards. 

If the dislocation is more complete, this margin begins to fall over 
backwards, as in the accompanying drawing ; and in more extreme 
cases the patella lies flat upon the outer side of the condyle, with its 
inner margin directed forwards. 

When the dislocation is partial, it is probable that neither the cap- 
sule nor the ligamentum patellae usually suffers much laceration ; but 
in complete dislocations the capsule at least must have given way 
more or less. Norris, of Philadelphia, reports a case of partial luxa- 
tion in which the complications were more serious. John Scanlin, set. 
32, was admitted to the Pennsylvania Hospital, on the 27th of August, 
1839, in consequence of injuries received a short time previous by 
having become entangled in machinery. In addition to several frac- 
tures in other limbs, he was found to have a subluxation of his left 
patella outwards, its outer edge being much raised 
and resting on the side of the external condyle of Fig. 278. 

the femur, while its inner edge was depressed, and 
firmly fixed in the hollow between the condyles. 
The internal lateral ligament of the knee was rup- 
tured, allowing the head of the tibia to be moved 
considerably outwards. A depression existed, also, 
between the tubercle of the tibia and the lower end 
of the patella, at the middle and inner side of the 
knee, evidently produced by a rupture of the liga- 
mentum patellae in nearly its whole extent. There 
was almost no swelling, and the limb was moderately 
flexed. By firm pressure the patella could be re- 
stored to position, but as soon as the hand was re- 
moved it returned to its original position. At the 
end of two months " a good degree of motion existed 
at the knee-joint, which was in no way inflamed or 
painful." 1 

Symptoms. —The limb is slightly bent, but im- 
movable; the breadth of the knee is considerably 
increased; the inner condyle projects unnaturally, 
and the patella is distinctly felt upon the outer side, 
tion is partial, the outer margin of the patella forms an irregular 
sharp ridge in front of the external condyle. If it is complete, the 
inner margin presents itself in front of the external condyle, and the 
outer margin looks backwards. Usually the patient suffers great pain 
as long as the dislocation remains unreduced. 

Watson, of New York, saw a case of complete dislocation of the 
patella outwards in a fat young lady with lax fibre, and occasioned 
by dancing. He says the knee was slightly but firmly flexed. It 
was reduced by a very slight pressure with the fingers, and although 




Dislocation of the pa- 
tella outwards. 

If the disloca- 



1 Norris, Amer. Journ. Med. Sei., vol. xxv., Feb. 1840, p. 276. 



688 DISLOCATIONS OF THE PATELLA. 

some inflammation with effusion into the joint ensued, the use of the 
limb was completely restored in a week or ten days. 1 

Prognosis. — Eeduction is in general easily accomplished, but a re- 
luxation is very prone to occur. In the few examples reported of a 
permanent luxation, the patients have eventually recovered the use of 
the limb in a great measure. Boyer saw four cases of this kind, in 
three of which it existed in the left leaf, and had remained from in- 
fancy. The patellae were easily replaced, but "unless confined they 
soon became displaced again ; not one of them found it necessary to 
apply for surgical aid, as " they suffered no great inconvenience from 
the luxation, and it exempted them from military service." 

After reduction, very little or no inflammation usually follows. 
Mr. Key has, however, narrated a case in Guy's Hospital Reports, of 
death from suppuration in the knee-joint, following upon the reduction 
of an inward subluxation. The dislocation was produced by a fall 
while carrying a pail, and was reduced by very gentle pressure ; but 
the patient, a girl, set. 20, although apparently in good health, was 
believed to be somewhat strumous. 2 

Treatment. — In order to relax completely the quadriceps extensor, 
by whose action chiefly the patella is held in its unnatural position, 
the body should be bent forwards, while at the same moment the leg 
is extended upon the thigh and the thigh flexed upon the body. The 
surgeon will accomplish these indications in the most simple manner, 
by placing the patient in a chair and then lifting the foot upon his 
own shoulder, as he kneels or sits before him. Sometimes the patella 
will resume its position at once when this manoeuvre is adopted; but 
if it does not, slight lateral pressure, made with the fingers, will gene- 
rally be found sufficient to accomplish the reduction. 

A man, set. 27, was sitting on a box and in jumping off tripped him- 
self with his right leg, causing a partial dislocation of the patella of 
the left leg outwards. Half an hour after the receipt of the injury I 
found him sitting, with the knee bent and in great pain. The patella 
lay upon the outer half of the articular surface, with its outer margin 
a little tilted upwards. Lifting the leg and thigh to a right angle with 
the body, and making very slight pressure upon the outer margin of 
the patella, it immediately resumed its place. Yery little inflamma- 
tion ensued. 

In some instances, where other means have failed, the reduction has 
been effected by violent flexion and extension of the knee, aided by 
lateral pressure. 

I have already mentioned, when speaking of dislocations into the 
foramen thyroideum, the case of 1ST. Smith, in whose person I found at 
the same moment a dislocation of the thigh, a subluxation outwards 
of the tibia, and a complete outward luxation of the corresponding 
patella. This was occasioned by a fall from a height upon the inside 
of the knee. I reduced the tibia first, and then easily replaced the 
patella by lifting the leg and pushing with my fingers against its outer 
margin. 

1 Watson, New York Journ. Med., vol. i. p. 306. 

2 Op. cit., vol. i. p. 260. 



DISLOCATIONS OF THE PATELLA UPON ITS AXIS. 689 

In many cases the patients themselves have reduced the dislocation 
immediately, and the surgeon is only consulted in relation to the after 
treatment. Liston says that this is so constantly the fact, or else such 
dislocations are really so rare, that it has never happened to him to 
have an opportunity of reducing any form of dislocation of the 
patella. 

Not long since, a young gentleman aet. 25, residing in Somerset, N". Y., 
called upon me in consequence of having discovered a floating carti- 
lage in his knee-joint. His account of the matter was that on the first 
of February, 1858, he was kicked by a cow upon the outside of the 
right leg about six inches below the knee, and that he immediately 
found the patella dislocated outwards. After several efforts he finally 
succeeded* in reducing it himself. His knee soon became greatly 
swollen, so that for five weeks he was unable to walk, and he has been 
more or less lame to this time. Six months after the accident he dis- 
covered a floating cartilage on the inside of the patella about one inch 
in diameter, which occasionally slips between the joint surfaces, and 
suddenly trips him up. 



§ 2. Dislocations of the Patella Inwards. 

Causes. — Less frequent than dislocations outwards, they are occa- 
sioned generally by direct blows received upon the outer margin of 
the patella. 

The symptoms, pathological anatomy, and treatment will be the 
same as in dislocations outwards, except so far as 
these must necessarily vary from the opposite posi- 
tion of the patella. 



§ 3. Dislocations op the Patella upon its Axis. 

Syn. — "Semi-rotation;" Miller. "Luxation Verticale ;" Mal- 
gaigne. 

These accidents, of which up to the present mo- 
ment not more than fifteen examples have been 
recorded, seem to be the result of the same causes 
which produce lateral luxations; and indeed they 
may be regarded as only exaggerated forms of in- 
complete lateral dislocations. In these latter acci- 
dents, as we have already noticed, the external or 
the internal margin of the patella, according as the 
subluxation is to the outer or inner side, is thrown 
more or less obliquely forwards; a position into 
which it is carried partly by the peculiar form of the 
articulating surfaces, and partly by the action of the vasti and rectus 
femoris muscles. If now these muscles were to contract suddenly 
and violently, and the return of the patella to its normal position was 
prevented by the lodgment of one of its margins in the inter-condylo- 
idean fossa, the other or free margin would be compelled to rise until 




Dislocation of the 
patella inwards. 



690 DISLOCATIONS OF THE PATELLA. 

it became perpendicular to the limb, or it might perhaps even become 
completely reversed in its socket. The signs of this accident are such 
as to render an error in the diagnosis almost impossible. The limb 
is generally found forcibly extended, occasionally it is in a position 
of moderate flexion, but the projection of the sharp border of the 
patella directly forwards under the skin, is itself sufficient to deter- 
mine the true nature of the injury. 

Kecluction may be effected by the same manoeuvres which we have 
recommended in lateral luxations; but if these measures do not suc- 
ceed, we may direct the patient to make a violent effort himself to 
flex and extend the limb, or the surgeon may force the limb into 
flexion and extension alternately, or he may rotate the tibia upon the 
femur, and then flex. Finally, he ought to make use of lateral pres- 
sure also, upon both margins of the upright patella, but in opposite 
directions. 

Watson, of New York, has related the following example of rota- 
tion of the patella upon its inner margin ("Luxation Yerticale Externe," 
Malg). 

Henry Burton, aged about thirty-five years, of rather slender frame, 
while riding on horseback in a crowd, received a blow upon his knee 
from a horse ridden by another person. When seen by Dr. Watson, 
soon after the accident, the leg was perfectly straight, but could be 
flexed to about an angle of 140° without causing pain. "The patella 
appeared to be slightly drawn up, and it was twisted upon its axis, 
presenting its outer edge, in a prominent hard line, in front of the 
knee; its inner edge was resting either in the groove between the 
condyles of the femur, upon which its posterior face should naturally 
play, or in the small depression on the anterior face of the femur, 
immediately above this groove. The anterior surface of the patella 
was turned inwards, its posterior surface outwards, and it rested nearly 
at right angles with its natural position. Its upper and lower attach- 
ments were both preserved, and could be distinctly felt; and a sort of 
band appeared to pass from its under, or, as it now lay, its outer face, 
inwards to the deeper portion of the knee-joint. This band, as I con- 
ceived, was caused either by the tension of the capsular ligament, or 
by the rupture of its edge, as it passes from the outer side of the 
patella. The position of the bone was so well marked that no one at 
all acquainted with the anatomy of the part could mistake the nature 
of the accident. 

"With the leg extended, and the anterior muscles of the thigh 
forced downwards as much as possible, pressure was made upon the 
patella with the expectation of forcing down its prominent edge. The 
effort was followed only by an increase of pain, the bone remaining 
permanently fixed. Another attempt was made to cant its posterior 
edge inwards, and to bring its anterior edge outwards, without press- 
ing it against the condyles of the femur, by forcing the head of a key 
against the posterior, now the outer face of the patella (using this as 
a fulcrum), and pressing the prominent edge of the bone toward the 
outer condyle. This manoeuvre gave him no pain, but was as fruitless 
in its result as the other. At length the knee was forcibly bent and 



DISLOCATIONS OF THE PATELLA UPWARDS. 691 

immediately straightened again ; and then by canting the patella as 
before, and pushing it slightly downwards and inwards, it sprung with 
a sudden snap into its proper position." 1 

Dr. Joseph P. Gfozzam, of Pittsburg, Pa., has met with a similar 
case. On the 10th of Sept., 1812, James Porter was thrown while 
wrestling, and immediately found himself unable to rise. Dr. Gtazzam 
saw him about an hour after the accident, and found the patella of the 
right leg dislocated on its axis, and resting on its inner edge in the 
groove between the condyles of the femur. Dr. Gr. proceeded to at- 
tempt reduction, but failed, after having made repeated trials by lift- 
ing the limb toward the body and by pressure in opposite directions. 
In consultation with Dr. Addison, it was now determined to divide 
the ligamentum patellae, which was done by introducing beneath the 
skin a narrow-bladed knife, and cutting close to the tubercle of the 
tibia. Again the attempts at reduction were renewed, but without 
success. The patella could be moved on its edge more freely than 
before the cutting, but resisted every effort to replace it. The patient 
was now bled in the erect posture and until the approach of syncope, 
but to no purpose. On the following morning, it was determined to 
adopt, with some modification, the mode practised so successfully by 
Dr. Watson. "The thigh was strongly flexed," says Dr. Grazzam, "on 
the pelvis, and the heel elevated. Then the leg was flexed steadily 
and forcibly on the thigh, and suddenly straightened. At the moment 
of straightening the leg, I pressed very strongly against the lower 
edge of the patella from without, with the head of a door key well 
wrapped, while Dr. Addison pressed with both thumbs against the 
upper edge of the bone toward the external condyle. On the fourth 
trial this manoeuvre succeeded, the bone springing into its place with 
a snap." Eecovery was uninterrupted, and two or three months after, 
the patient had the complete use of his limb. 2 

In a case of the same kind, published originally in Rust's Magazine, 
and which is copied at length by Mr. B. Cooper in his edition of Sir 
Astley's great work, the reduction was found impossible, notwith- 
standing the surgeon finally had the temerity to sever completely the 
tendon of the quadriceps extensor, and the ligamentum patellae. Ex- 
tensive suppuration followed, under which the poor fellow finally 
sank and died. 

It is scarcely necessary to say that, rather than expose the patient 
to such hazards, it would be better to leave the bone unreduced. 



§ 4. Dislocations of the Patella Upwards. 

Occasionally the ligamentum patellae has been found so much elon- 
gated and relaxed, as to permit the patella to glide upwards upon the 
front of the femur. Heister and Ravaton have each seen an example 
in which a displacement from this cause existed to the extent of three 
inches. It is much more common, however, to meet with this dislo- 

i Watson, New York Journ. Med., Oct. 1839, p. 302. 

3 Gazzam, Amer. Journ. Med. Sci., vol. xxxi. April, 1843, p. 363. 



692 DISLOCATIONS OF THE HEAD OF THE TIBIA. 

cation as a result of a rapture of the ligamentum patellae, as the fol- 
lowing example will illustrate. 

On the 18th of Dec., 1850, Dennis Milliards, set. 50, was admitted 
to the surgical wards of the Buffalo Hospital of the Sisters of Charity. 
While at work on this same day, he had slipped and fallen, with his 
knee forcibly flexed under his body. I found the ligament of the 
patella torn asunder and the patella drawn up two or three inches 
upon the front of the thigh. We applied at once the dressings used 
by me for a broken patella, and were able to bring the bone down 
completely to its place. Three weeks from the time of the receipt of 
the injury, the dressings were removed, and the patella was found to 
be nearly but not quite in its original place. From this time we 
commenced to move the joint : in about ten days more he left the 
hospital, and I lost sight of him, so that I am unable to speak more 
definitely of the result. 

Gibson has recorded a similar case, in which both patellae were dis- 
located upwards by a rupture of the ligaments, occasioned by the 
exercise of leaping. He recovered the use of his limbs almost com- 
pletely. 1 

(For examples of rupture of the quadriceps femoris, which some 
writers have incorrectly named Dislocations of the Patella Down- 
wards, see Velpeau's Surgery, 1st Amer. ed., vol. i. p. 422 ; New York 
Med. Times, April 6, 1861, p. 226, and two cases reported by myself 
in the same vol. of the Med. Times) 



CHAPTER XYIII. 

DISLOCATIONS OF THE HEAD OF THE TIBIA. 

Syn. — "Tibia upon the femur ;" "dislocations of the leg." 

In consequence of the great size and irregularity of the articular 
surfaces between the tibia and femur, together with the remarkable 
number and strength of the ligaments which bind the two bones 
together, dislocations at this joint are exceedingly rare. They are 
known to take place, however, in four principal directions, namely, 
backwards, forwards, inwards, and outwards. A dislocation may also 
occur in either of the diagonals between these points, that is, antero- 
laterally, or postero-laterally. They may be either complete or incom- 
plete. Velpeau has found upon record thirteen examples of complete 
dislocations forwards, and eight backwards, but not one of a complete 
lateral luxation. Yelpeau thought also that the antero-posterior 
luxations were always complete, but Malgaigne has shown that this 
opinion is erroneous. 

Simple flexion and extension, however extreme, are generally insuf- 

1 Gibson; Surgery, vol. i. p. 395, 6th ed. 



DISLOCATIONS OF HEAD OF TIBIA BACKWARDS. 693 

ficient to produce either of these dislocations. They may be produced 
by a violent blow upon the lower end of the femur, or upon the upper 
end of the tibia, or by twisting the tibia upon the femur, as when the 
foot is made fast in a hole, and the body swings around upon the 
knee. 



Fig. 280. 



§ 1. Dislocations of the Head or the Tibia Backwards. 

Symptoms. — The head of the tibia is felt in the popliteal space; and, 
if the dislocation is complete, the pressure upon the popliteal nerve 
becomes excessively painful. 

A marked depression exists in front, immediately below the patella, 
and especially upon the sides of the ligamentum patellae; the con- 
dyles of the femur project strongly in front ; the leg may be not at all, 
or only slightly shortened, or the shortening may amount to one inch 
or more, and usually it is in a position of extreme extension, or thrown 
forwards from the line of the axis of the femur ; but its position has 
been found to vary greatly in different cases, the limb being some- 
times very much flexed, and in others very slightly flexed, or perfectly 
straight. 

Pathological Anatomy. — The posterior ligament of the joint is torn; 
the muscles of the ham are put upon the stretch; the popliteal nerves 
and vessels compressed ; and the head of the tibia either rests partly 
upon the posterior half of the lower articulating surface of the femur, 
or it passes up and rests only against its posterior articulating surface, 
which in this direction extends an inch or more upwards. If the dis- 
location is complete, the crucial ligaments are 
also torn, and all the parts about the joint suffer 
extensive injury from stretching, laceration, or 
compression. 

Prognosis. — Malgaigne has seen three ex- 
amples of incomplete backward luxations which 
were not reduced, and neither of the persons 
were very greatly maimed in consequence. One 
walked with crutches after three or four days, 
and with a cane after about five weeks. Ano- 
ther did not leave his bed under one month, 
and it was nearly one year before he could lay 
aside his crutches ; but both of them were finally 
able to walk at least twelve leagues per day. 
Malgaigne informs us, however, that in a simi- 
lar case seen by Lassus, the patient was con- 
fined to his bed two years, although he finally 
recovered a tolerable use of his limb. 

If the reduction is promptly effected, the 
limb kept perfectly quiet a sufficient length of 
time, and in other respects properly managed, not much inflammation 
need generally to be anticipated, and the limb may suffer in the end 
very little, if any maiming. 

Treatment. — It will be proper, at first, to attempt the redaction by 




Dislocation of the 
the tihia backwards. 



694: DISLOCATIONS OF THE HEAD OF THE TIBIA. 

simple manipulation, as this is often found to succeed when the dis- 
location is recent and incomplete, and especially when the system is 
greatly depressed by the shock of the injury. If the dislocation is 
complete, however, we can hardly anticipate success without the ap- 
plication of some extending force. 

In the employment of manipulation we ought to be governed at 
first by the same rule which we have found so generally applicable in 
dislocations of the femur, namely, to carry the limb in those directions 
in which it will move easily, or without much force. If this fails, we 
may at once resort to forced flexion alternating with extension, rotat- 
ing or rocking the limb also occasionally from one side to the other, 
while at the same moment strong pressure is made upon the project- 
ing bones at the knee-joint in opposite directions or in the direction 
of the articulation. 

Finally, it may be necessary to resort to extension, made by means 
of a lacq, or by the hands of strong assistants, above the ankle, always 
at first in the direction of the axis of the tibia ; the counter-extending 
band being applied to the perineum, if the leg is straight, but to the 
lower and upper part of the thigh, if the leg is flexed. 

A very convenient mode of making extension where we wish to 
apply more than usual force, is to lay the whole limb over a firm 
double inclined plane, or fracture splint, securing the thigh to the thigh- 
piece with a roller, and making the extension with the screw attached 
to the foot-board. This method, however, while it enables us to use 
great force in the extension, prevents the surgeon from employing, at 
the same time, those flexions, extensions, and other manipulations, 
upon which success so often depends. 

Mr. Eose has related in the Provincial Medical Journal of June 11th, 
1842, a characteristic example of this accident, except that the patella 
had also suffered a lateral displacement, presenting the usual favorable 
termination. 

A woman was standing upon a low ladder, when a carriage driven 
furiously came in contact with it, and precipitated her to the ground. 
Dr. Eose, who saw her almost immediately, found the tibia completely 
dislocated at the knee, the head being driven behind the condyles of 
the femur into the ham, with the patella thrown to the outside of the 
external condyle, and the leg in a state of fixed extension. Immedi- 
ately, and without difficulty, the bones were restored by applying one 
hand to the patella, the other to the back of the upper portion of the 
tibia, and simultaneously pulling and pushing those bones toward 
their natural positions. The patient was then removed to a bed, and 
b}~ the diligent use of antiphlogistic remedies inflammation was kept 
in check, and the case reached a favorable termination without one 
untoward symptom. After the lapse of only a few weeks, she had 
completely recovered the use of the knee-joint. 1 

Dr. Walsham communicated a case to Sir Astley Cooper, in which 
the dislocation was not only complete, but the tendon of the quadriceps 
extensor was ruptured. The leg was bent forwards. The reduction 

1 Rose, Amer. Journ. Med. Sci., vol. xxsi. p. 216. 



DISLOCATIONS OF HEAD OF TIBIA FORWAEDS. 695 

was accomplished very easily by extension made with the hands by 
four men, in the line of the axis of the limb. In about one month, 
this man began to walk with crutches, but he was not perfectly re- 
covered until after five months; at which time the crutches were 
finally laid aside. 1 



Fig. 281. 



§ 2. Dislocations op the Head of the Tibia Forwards. 

The signs of this accident are the reverse of those which belong to 
dislocations backwards. The patella, tibia, and fibula, are prominent 
in front, while the condyles of the femur may be felt behind, pressing 
strongly upon the muscles, nerves, and bloodvessels which occupy the 
popliteal space. In case the dislocation is complete, a shortening may 
exist to the extent of one or even three inches. Dr. O'Beirne, of 
Dublin, has mentioned a case to Mr. B. Cooper, in which the shorten- 
ing was three inches and a half, and Mr. Mayo has seen one example 
in which the dislocated limb was "fully four inches" shorter than the 
other. 2 It is quite probable, however, that these latter statements are 
somewhat exaggerated. 

In consequence of the pressure upon the popliteal artery, the pulsa- 
tions in the branches below are frequently interrupted, and in one 
instance this pressure was sufficient to produce finally a dry gangrene. 

Dr. Gorde relates a case in the Bulletin de Thirapeutique, occurring 
in a woman nearly sixty years old. This woman was returning home 
at night with a heavy burden, and in a 
state of intoxication, when she stepped 
into a ditch as deep as up to the middle of 
her thighs. The body was thrown for- 
wards by the fall while the feet stuck at 
the bottom of the ditch ; the whole force 
of the impulse being sustained by the 
thighs. The lower end of the femur was 
found driven downwards and backwards, 
and lodged under the muscles of the calf 
of the leg ; the limb being shortened three 
inches. Eeduction was promptly effected, 
and without inflicting any pain of which 
the patient complained. In six weeks the 
patient was cured. 3 

Mr. Toogood has reported also, in the 
Provincial Medical Journal of June 18th, 
1842, an example of complete dislocation 
in this direction, in which the appearance 
was so dreadful, that Mr. Toogood at first 

despaired of being able to reduce it ; but by directing two men to 
make counter-extension while he made extension, the reduction was 




Dislocation of the head of the tibia 
forwards. 



1 Walsham, Sir A. Cooper on Disloc, &c, 2d Loud, ed., p. 188. 

2 B. Cooper's ed. of Sir Astley Cooper on Disloc, &c, pp. 214-215. 

3 Gorde, Amer. Journ. Med. Sci., vol. xvi. p. 225, May, 1835. 



696 DISLOCATIONS OF THE HEAD OF THE TIBIA. 

immediately effected. At the end of one month the patient was able 
to leave his bed ; and sixteen years after, Dr. Toogood saw him walk- 
ing "with very little lameness." 1 Parker, of Liverpool, has reported 
another example in the London and Edinburgh Monthly Journal for 
December, 1842, which was occasioned by the fall of a heavy spar 
upon a man's back, and the consequent violent bending of the knee 
under his body. In this case the limb was slightly flexed, and the 
patella was loose and floating. The reduction was effected without 
much difficulty by extension and counter-extension made by two men, 
while the operator, placing his knee in the ham of the patient, attempted 
to bring the leg to a right angle with the thigh. 2 

B. Cooper, Malgaigne, Little, 3 and others, have recorded examples 
of this accident. 

March 9th, 1865, Hiram Wescott, of Sandy Cove, Nova Scotia, set. 
45, was caught by his sled, drawn by horses, in such a way that a 
beam pressed against the front and lower end of the femur while the 
heel was caught and arrested by a stump. The foot was thrown for- 
wards and the upper end of the tibia completely dislocated in the 
same direction. It was at once reduced by a person who was present, 
but on attempting to use the leg in walking it was reluxated immedi- 
ately. Mr. J. H. Harris, medical student, found the limb soon after 
completely luxated, with the leg thrown forwards in the position of 
dorsal flexion about 40°. The tendons of the hamstring muscles were 
not ruptured, but had slid forwards past the condyles of the femur. 
There was no external wound. Keduction was easily accomplished 
by simple extension. Pasteboard splints were then applied. On the 
third day the knee was considerably swollen and some ecchymosis 
existed about the popliteal region. On the fifth day these symptoms 
had much increased. Mr. Harris then applied extension to the foot, 
with the aid of adhesive plaster, pulley and weights, and by elevating 
the foot of the bed. The amount of extension employed was 9 lbs. 
This gave immediate relief to the pain, and was continued until the 
inflammation subsided. His recovery was steady, and in four months 
he walked with crutches or a cane. 

In 1864 a similar dislocation was presented at the Brooklyn City 
Hospital, in which reduction having been practised the patient died. 
The case is reported very fully by Dr. Le Eoy M. Yale. 4 

Dr. White, of Buffalo, politely invited me to see with him a lad, set. 
10, whose tibia had been partially dislocated forwards eight weeks 
before, by a boy's having hit the top of his knee with his head, while 
they were at play. His father, who is himself a physician, residing 
near town, reduced the limb very easily, by extension made with his 
own hands, and by pressing upon the projecting bones. Violent in- 
flammation ensued, but at the time when I saw him, the knee was 
free from soreness or swelling, and the motions of the joint were nearly 
restored. 

1 Toogood, Amer. Journ. Med. Sci., vol. xxxi. p. 465. 2 E. Parker, ibid. 

3 Little, New York Med. Times, Aug. 17, 1861. 

4 Yale, N. Y. Journ. Med., vol. ii. p. 124, Nov. 1865. 



DISLOCATIONS OF HEAD OF TIBIA OUTWAKDS. 



697 



§ 3. Dislocations of the Head of the Tibia Outwards. 

Occasionally, owing to a violent wrench of the knee-joint, the late- 
ral ligaments upon one side or the other are ruptured, and conse- 
quently the joint surfaces separate somewhat from each other, or when 
the limb is moved, the head of the tibia may slide a little forwards or 
backwards, or to either side. These are not properly examples of 
subluxation : nor should we consider as belonging to this class the 
accident originally described by Mr. Hey, as an " internal derange- 
ment of the knee-joint," but which also by some writers has been 
termed a " subluxation of the knee." Of this latter accident, I will 
take occasion hereafter to speak a little more particularly. 

In subluxation, properly so called, if the direction of the disloca- 
tion is outwards, the outer condyle of the femur rests upon the inner 
articulating surface of the tibia, and if the direction of the dislocation 
is inwards, the inner condyle of the femur rests upon the outer articu- 
lating surface of the tibia. 

The signs which characterize this accident are such as cannot easily 
be mistaken. The limb is not shortened, nor is there anything espe- 
cially diagnostic in its position, since it has been found to be some- 
times flexed, and at other times straight; but the strong lateral 
projections made by the inner condyle of the femur on the one hand, 
and by the heads of the tibia and fibula on the other, cannot fail to 
inform us as to the true nature of the accident. 

The treatment will not differ essentially from that which has 
already been recommended in dislocation of the tibia backwards or 
forwards. If any other expedients can prove use- 
ful, they must be left to the judgment of the sur- 
geon whenever the exigencies of the case shall 
demand them. 

I have already mentioned the case of K. Smith, 
who, in consequence of a fall from a window, had 
a dislocation of the right femur, tibia, and patella. 
The tibia was subluxated outwards, and the leg 
was partially flexed upon the thigh, with the toes 
everted. By moderate extension, made with my 
own hands, united with alternate flexion and ex- 
tension, the bone was easily and promptly restored 
to its place. Having reduced the femur also, the 
limb was laid over a gently inclined plane made 
of pillows ; and cloths moistened with cool water 
were kept constantly applied to the knee for many 
days. Very little swelling followed the accident, 
and his recovery was rapid and complete. 

A man was received into the North London 
Hospital, with a partial dislocation of the tibia 
outwards, and although the knee was much swol- 
len, the nature of the injury was easily determined. The knee was- 
immovable, and the toes turned outwards. Mr. Hallam, the house 
45 



Fig. 282. 




Subluxation of the head 
of the tibia outwards. 






: : = l ■: : a t : : >~ 



OF TH 



I A 



surgeon, reduced it by extension and counter-extension made by his 
own hands 

Air. Pitt records a similar case in a young lady, produced by a fall 
down a flight of stairs. It was red;:-.", easily by extension and 
counter-extension. Inflammation followed, but it was finally con- 
trolled, and she regained the use of her limbs. 2 

In one case of subluxation, mentioned by Sir Astley Cooper, and 
in a second recorded by Bransby Cooper, the recovery of the func- 
tions of the joint did not seem to have been so rapid ; the joint re- 
maining unstable and tender for a loner time after w:.. 



2S3. 



§ 4. Dislocations of the Head of the Tibia Ixwabds. 

There is nothing peculiar in either the signs, condition, or treatment 
of this accident, as distinguished from a dislocation outwards :: le- 
mand of us a special consideration. 

Sir Astley Cooper has mentioned two cases of subluxation inwards, 
and Mr. B. Cooper has added to these a third. Sir Astiey remarks 
that in the first accident, the only one indeed which he had himself 
ever seen, he was struck with three circumstances: first, the great 
deformity of the knee from the projection of the tibia: second, the 
ease with which the bone was reduced by direct extension: and third, 
by the little inflammation which followed. The second case of which 
Sir Astley speaks was communicated to him by a Mr. Eichards. In 
this case the fibula was also broken, and the reduction was a : 

plished only after extension had been made >y 
several persons for half an hour. The limb became 
excessively swollen, and remained so for many 
weeks. Eighteen months after the accident the 
knee continued somewhat stiff, and there was an 
unnatural lateral motion in the joint, from the in- 
jury which the ligaments had sustained. The pa- 
tient referred to by Bransby Cooper had met with 
the accident by a fall upon the foot with his Leg 
bent under him ; and a fellow workman had re- 
duced the bone by extension and pressure. Mr. 
Cooper thinks that not only the internal lateral 
ligament was torn, hot also some fibres of the vas- 
tus externus and the crucial ligaments. Violent 
inflammation ensued, which did not permit him to 
leave the hospital until after about two weeks :- 
Fergussoii has seen two examples of unreduced 
6 o "iuxation inwards, in both of which the patients 
... . had regained useful limbs. 5 

r.:.:-r.:::::::r:T-.: - . . 

«f the tibia inwards. Alalgaigne mentions that boyer, Costallat, and 




1 Hallam. Airier. Jourr.. Med. Sci., voL xix. p. 251. 

2 Pitt, ibid., vol. xxxi. p. 465. 

3 B. Cooper's ed. of Sir Ast.. or-. c:t.. pp. 111—13-- 
• Ibid., pp. 211-13. 

' Fergnsa o, ._ sit., p. 284* 



HEAD OF THE TIBIA BACKWARDS AND OUTWARDS. 699 

Key, had each seen one similar example ; and he also enumerates two 
additional cases of complete luxation attended with a protrusion of 
the bone through an external wound; in both of which the reduction 
was easily effected and the patients recovered. 1 

§ 5. Dislocations of the Head of the Tibia Backwards and Outwards. 

In June, 1853, Henry J., of Dansville, N. Y., set. 24, was thrown by 
an enraged bull, and his left leg being caught under the knee by the 
horns, was twisted violently. Dr. Prior, of Dansville, and Batton, of 
Burns, were called, and found the left knee completely dislocated ; 
the tibia being displaced backwards beyond the condyles of the femur 
and also a little outwards. The foot and leg were inclined outwards. 
With tbe assistance of four men, extension and counter-extension were 
made in the line of the axis of the limb, and the reduction was easily 
accomplished. Pasteboard splints, bandages, &c, were applied to 
maintain the bones in place ; but the swelling came on rapidly, and 
in the evening these dressings were removed. The limb was now laid 
over a double inclined plane carefully padded, in order to press the 
upper end of the tibia forwards, as it manifested a constant inclination 
to become displaced backwards. This apparatus was employed six 
weeks, with the exception of two or three days, during which the 
limb was laid upon pillows, but as the pillows did not sufficiently 
support the back of the tibia, the double inclined plane was resumed. 
After the removal of the plane, during seven weeks longer, an angular 
splint was kept closely applied to the back of the limb. 

Seven months after the accident, on the 23d of January, 1854, Dr. 
Eobinson, of Hornellsville, brought the gentleman to me. I found the 
bones displaced backwards about three-quarters of an inch, and half 
an inch outwards, or to the fibular side. This was the position of the 
bones when he was sitting with his leg bent at a right angle with the 
thigh, but when he stood erect and bore some weight upon the foot, 
the outward displacement ceased, and the backward displacement only 
remained. It was very easy, however, in whatever position the leg 
might be, to push the bones forwards by the hands until nearly all 
deformity had disappeared. He could flex the leg to a right angle 
with the thigh, and straighten it completely, but he could not lift the 
foot and leg from the floor while sitting with his limb extended in 
front of him. He was unable to bear sufficient weight upon his foot 
to use it at all in progression, on account of the inability to fix and 
steady the limb, but not on account of any pain or soreness which it 
occasioned. 

It was very plain that the surgeons were not in fault for this un- 
fortunate condition ; indeed they seem to have exercised throughout 
great ingenuity and skill in its management. 

I directed the young man to Mr. John C. Seiffert, of Buffalo, a very 
ingenious instrument maker, who has since succeeded, I learn, in 
adapting to his knee a mechanical contrivance which enables him to 
walk quite well. 

1 Malgaigne, op. cit., torn. ii. p. 953. 



700 DISLOCATIONS OF THE HEAD OF THE TIBIA. 

Thomas "Wells, of Columbia, South Carolina, has described a similar 
accident, the tibia being dislocated outwards and backwards, which 
terminated fatally on the fourth day in consequence mainly of ex- 
posure, intemperance, and neglect to apply for surgical aid. The 
bones were never reduced, and the autopsy disclosed also a fracture 
of the internal condyle of the femur. 1 



§ 6. Internal Derangement of the Knee- Joint. 

Syn. — " Slipping of the semilunar fibro-cartilages ;" Hey. " Partial dislocation of the 
thigh-bone from the semilunar cartilages;" Sir Astley Cooper. "Subluxation of the 
semilunar cartilages ;" Malgaigne. " Subluxation of the knee ;" Erichsen. To these 
we think it proper to add, as giving rise to the same class of symptoms, " Floating 
cartilages in the knee-joint." 

We have already expressed our opinion that this accident is in no 
proper sense a subluxation of the knee; and we should not, therefore, 
think it worth while to make any farther allusion to it, were it not neces- 
sary in order to enable the student of surgery to distinguish between 
the phenomena which belong to it and those which belong strictly to 
subluxations of this joint. 

Symptoms. — The patient is suddenly thrown to the ground while 
walking, as if by an instantaneous loss of power in the affected limb, 
this loss of control over the limb being accompanied usually with 
sharp pain, referred to the region of the knee-joint; or he trips his 
toe against something in his path, and the toes becoming everted, the 
leg suddenly gives way under him ; in some cases it has happened 
when the patient was turning in bed, the weight of the bedclothes 
hanging upon the toes so as to occasion a strain and rotation outwards 
at the knee-joint, or it follows upon a subluxation of the joint, as in 
one example which I shall presently relate. 

If the patient is walking when the accident takes place, and he falls 
to the ground, he finds himself unable to move the limb, or to stand 
upon it ; but by manipulation, the difficulty is, in most cases, as easily 
overcome as it occurred, when immediately the motions of the joint 
become free, and he walks off as if nothing had happened. 

When the accident has once taken place, it is afterwards exceed- 
ingly liable to occur from very slight causes, and eventually the knee- 
joint becomes tender and the capsule fills with synovia, indicating the 
existence of subacute synovitis. 

A single example will illustrate the usual history of these cases. 

A young man, from Colesville, N". Y., set. 23, consulted me on the 
27th of Oct. 1858, in relation to the condition of his knee-joint. He 
stated that on the 13th of Aug. 1858, while standing with the whole 
weight of his body resting upon the left leg, a mate struck him on the 
inside of the lower end of the left femur. The blow was made with 
the palm of the hand, but with sufficient force to throw him down. It 
was immediately noticed that the tibia was partially dislocated inwards 
at the knee-joint. The whole lower part of the limb was inclined 

1 Wells, Amer. Journ. Med. Sci., vol. x. p. 25, May, 1832. 



IXTERXAL DBKANGEMENT OF THE KSFEE-JOINT. 701 

outwards. A person present in the room seized upon the foot and 
by extension easily brought it back to place ; the bone resuming its 
position with an audible snap. After this he continued to walk about 
until night. Two days after, the knee had become so much inflamed 
that he was obliged to take to his bed, on which he was confined three 
weeks. Gradually the swelling subsided, and in about five weeks 
after the accident he began to walk on crutches. On the 23d of Sept., 
he was walking in the store without crutches, when he suddenly felt 
a sensation of slipping in the joint, and he fell to the floor as if he 
had been tripped up. At the time when he called upon me, this had 
happened many times, but has never been attended with pain. The 
joint was filled with synovia, and tender, yet I could distinctly feel a 
hard body just to the inside of the ligamentum patellae, and which 
moved freely under the finger. 

Pathological Anatomy. — The same class of symptoms, with only 
very slight modification, belongs probably to several varieties of "in- 
ternal derangement of the knee-joint ;" and first it will be remembered 
that the semilunar cartilages upon which the margins of the condyles 
of the femur rest, are attached to the tibia by several ligaments ; but 
when, from relaxation or a violent strain, any one of these ligaments 
becomes elongated or gives way, the portion of cartilage which it 
restrains is permitted to become partially displaced, and by interposing 
its thick margin between the deeper articulating surfaces the bones are 
separated and the muscles lose their control over the joint; second, 
these ligaments may not only yield, but a fragment of one of the car- 
tilages may become actually broken off from the main portion ; third, 
the femur may perhaps escape behind some portion of an interarticular 
cartilage, and thus, instead of the cartilage placing itself between the 
joint surfaces, the femur itself may have thrust it into this position ; 
fourth, a cartilage or some portion of a cartilage may become hyper- 
trophied, and thus give rise to the symptoms described ; fifth, in other 
cases still, a bony, cartilaginous, fibrinous, or calcareous growth or 
concretion forming within the joint, and if originally attached, becom- 
ing separated from the capsule, may move about more or less freely, 
and give rise to the same class of symptoms which we have described. 

This last variety has generally been described under the name of 
"floating cartilages;" but since these bodies are not always cartilagi- 
nous, and especially since they do not always by any means move so 
freely as to be properly designated as "floating," the term is less 
appropriate than that originally given by Hey, and which we have 
chosen to adopt. 

Treatment. — For the purpose of obtaining immediate relief it is gene- 
rally sufficient to flex the leg completely and then suddenly extend 
it, or to combine this motion with a slight twisting or rocking of the 
knee-joint. Sometimes this experiment has to be repeated several 
times before it is completely successful, and in a few instances it has 
failed altogether. I think I must have met with ten or twelve ex- 
amples in the course of my practice, and in no instance has the sudden 
flexion and extension of the limb failed to overcome the difficulty. 

As to the question of subsequent treatment, especially as to whether 



702 DISLOCATIONS OF LOWEK EXD OF THE TIBIA. 

it is proper to attempt their extirpation when they are found to be 
loose, or to make any other surgical interference, I prefer to leave its 
consideration to those general treatises upon surgery where it more 
properly belongs. 



CHAPTEE XIX. 

DISLOCATIONS OF THE LOWER END OF THE TIBIA. 

Syn. — " Tibio-tarsal luxations;" Malgaigne. "Dislocations of the ankle-joint;" 
Chelius and others. 

The tibia may be dislocated at its lower end in four directions ; 
namely, inwards, outwards, forwards, and backwards. Most of these 
dislocations complicate themselves with fractures of the fibula, or of 
the tibia, or with fractures of both bones. 

Dupuytren, Malgaigne, and a few other surgeons have reported ex- 
amples also of dislocations forwards and inwards. 

Boyer, with a majority of the French writers, and several English 
and German surgeons, speak of these dislocations as belonging to the 
foot; consequently the outward dislocation of Boyer is the inward 
dislocation of Sir Astley Cooper, Malgaigne, myself and others, who 
prefer to regard the tibia as the bone dislocated. 

§ 1. Dislocations op the Lower End of the Tibia Inwards. 

Syn. — "Inward tibio-tarsal luxations ;" Malgaigne. "Dislocations of the foot out- 
wards;" Boyer and others. 

Causes. — This dislocation is occasioned generally by a fall from a 
height, upon the bottom of the foot, the foot receiving at the same 
moment a sufficient inclination outwards to determine the main force 
of the impulse toward the inner side of the ankle. It may be pro- 
duced also by a blow received directly upon the outside of the leg 
just above the ankle, or by a violent twist or wrench of the foot out- 
wards. 

Pathological Anatomy. — I have already, in the chapter on fractures 
of the fibula, stated my opinion that a large majority of those acci- 
dents which have been called inward and outward dislocations of the 
tibia, were merely examples of lateral rotation of the astragalus within 
the half ginglimoid and half orbicular socket formed by the lower 
extremities of the tibia and fibula ; and that true dislocations, either 
partial or complete, are at this joint and in these directions very rare 
occurrences. We shall continue, however, in accordance with the 
general practice of writers, to call them all dislocations, whether the 
astragalus simply rotates on its axis, or is displaced laterally and hori- 
zontally from the tibia. 







DISLOCATIONS OF LOWER END OF TIBIA INWARDS. 703 

In the most common form of the accident, then, when the foot is 
violently twisted outwards, the astragalus becomes tilted upon its outer 
and upper margin in such a way as that this margin slides inwards 
and places itself underneath the middle portion of the lower articu- 
lating surface of the tibia; its upper and inner margin descends 
toward the extremity of the 

malleolus internus, and the out- Fi g- 284 - 

er face of the astragalus pre- 
sents obliquely upwards and 
outwards, instead of directly 
outwards as it would do in its 
natural position. This cannot 
occur without a rupture of the 
internal tibio-tarsal ligaments, 
or a fracture of the malleolus 
internus, or both; indeed a frac- 
ture of the internal malleolus 
is a very common circum- 
stance in connection with this 

form Of dislocation. Much Dislocation of the lower end of the tibia inwards. 

more frequently, however, the 

fibula itself gives way at a point within from two to five inches of its 
lower extremity; or sometimes the fracture in the fibula occurs 
through that portion which forms the malleolus externus. For more 
particular information as to the causes and relative frequency of these 
fractures, I refer the reader to the chapter on fractures of the fibula. 

Barely it happens that instead of this lateral rotation of the astra- 
galus, there occurs a true lateral displacement of the tibia inwards 
upon the astragalus, and the outer portion of the lower articulating 
surface of the tibia comes to rest upon the inner portion of the upper 
articulating surface of the astragalus; or it may slide completely off 
in the same direction; a result which is usually attended with a lacera- 
tion of the muscles and integuments, converting the accident into a 
compound dislocation. In some cases this extreme displacement occurs 
without such lacerations. 

In this form of the accident, the true lateral luxation, the fibula may 
remain unbroken and undisturbed, the tibia merely having become 
displaced inwards ; or the fibula may give way also above the articula- 
tion, while the malleolus internus, and the internal lateral ligaments 
are equally liable to rupture as in the other form of the accident. 

Sometimes in addition to these complications, the lower end of the 
tibia is found to be broken obliquely upwards and outwards from the 
articulating surface, leaving that fragment attached to the fibula which 
corresponds to the inferior peroneo-tibial articulation. 

Symptoms. — The foot is more or less violently abducted, the sole of 
the foot presenting downwards and outwards instead of directly down- 
wards ; the malleolus internus projects strongly at the inner side of 
the joint ; and at the outer side there is a corresponding depression, 
generally most marked a little above the articulation near the point 



704 



DISLOCATIONS OF LOWER END OF THE TIBIA. 



of fracture in the fibula. The pain is very great and the foot is 
immovably fixed, so far as the volition of the patient can determine 
motion, but the surgeon can generally move it pretty freely, yet not 
without causing a great increase of the pain. When the dislocation 
is complete, and the fibula also is broken, the limb becomes slightly 
shortened. 

Fig. 285. 




Dislocation of the lower end of the tibia inwards. 



Treatment. — "When the accident is of the nature of a simple rotation 
of the astragalus upon its axis, the reduction is often accomplished 
with the greatest ease by seizing upon the foot, and forcibly adducting 
it. Not unfrequently the patient himself, or some other person who 
is present, has effected the redaction before the surgeon is called. In 
other cases, and especially when it partakes of the nature of a true 
dislocation, much difficulty is sometimes experienced in the reduction. 
The surgeon ought then to flex the leg upon the thigh, in order to 
relax the gastrocnemii muscles, and holding the foot midway be- 
tween flexion and extension, he should pull steadily upon it with his 
own hands, while an assistant makes counter-extension, and supports 
the limb with his hands, grasping the thigh above the knee. At the 
same moment lateral pressure should be made upon the projecting 
bone in the direction of the articulation. It is of some use, also, to 
occasionally flex and extend the limb moderately, and to give to the 
foot a gentle rocking motion. If more force is needed, it may be ap- 
plied by placing the limb over a firm double inclined fracture splint, 
and making the extension by the aid of a screw attached to the foot- 



DISLOCATIONS OF LOWER END OF TIBIA INWARDS. 705 

board, as we have suggested in certain cases of dislocation at the knee. 
Or we may employ the pulleys after the manner represented in the 
accompanying drawing. 

Fig. 286. 




Charles Sauer, of this city, aged about thirty years, while carrying 
a weight upon his shoulders, on the 6th of May, 1854, slipped upon 
the side-walk, and fell, dislocating the left tibia inwards, and frac- 
turing the fibula four inches from its lower end. I was in attendance 
soon after the accident occurred, and found the tibia projecting inwards, 
with the other symptoms usually accompanying a simple rotation of 
the astragalus upon its axis. Seizing the foot with my hands, and 
flexing the leg, while an assistant held up the thigh and made counter- 
extension, I had scarcely begun to pull upon the foot before the re- 
duction was effected. Dupuytren's splint was at once applied, and 
the subsequent inflammation was so trivial as scarcely to deserve 
notice. In six weeks the limb was sound, and free from all anchy- 
losis. 

In my report on dislocations, made to the New York State Medical 
Society for the year 1855, 1 have mentioned twelve similar examples, 
in addition to some examples of compound dislocations, all of which 
were easily reduced, but the results were not always so favorable. 

If, as rarely happens, the tibia is broken obliquely into the joint, 
the complete reduction of the dislocated tibia may be found impos- 
sible, owing to the obstacle presented by the displaced fragment. 

The following I am disposed to regard as examples of dislocation 
accompanied with fracture of the tibia within the articulation. 

Brockway, of Cortland, N. Y., aged about twenty-seven years, con- 
sulted me at my office a few years since in relation to the condition of 
his foot. I found the tibia dislocated inwards, and projecting more 
than an inch beyond the astragalus; the sole was turned outwards, 
compelling him to walk upon the inside of his foot ; the fibula was 
bent inwards against the tibia, at a point about four inches above the 
ankle, which seemed to have been the seat of fracture of this bone. 
He stated to me that immediately after the receipt of the injury, 
which was occasioned by a fall from a height upon the bottom of his 



706 DISLOCATIONS OF LOWER END OF THE TIBIA. 

foot, he had consulted a surgeon, Dr. A. B. Shipman, of Cortland, 
and that although Dr. Shipman made repeated and violent efforts to 
effect the reduction, he had been unable to do so. Indeed, the bone 
had never been removed from the position in which it was at first 
placed. 

J. Borland, of Erie Co., N. Y. ; set. 31, fell under a rolling log, and 
dislocated his left tibia inwards, breaking off the internal malleolus, 
and fracturing the fibula four inches from its lower end. Dr. Sweet- 
land, an old and experienced practitioner, was immediately called, who, 
with another surgeon, failed, after repeated efforts, to reduce the 
dislocation. I saw the patient, in consultation with these gentlemen, 
twenty -four hours after the accident. The foot and ankle were some- 
what swollen, and discolored. The lower end of the tibia projected 
so far inwards as to threaten a rupture of the skin ; the foot was- 
strongly everted. We first flexed the leg upon the thigh, and made 
extension with our hands, in the manner I have already directed. 
This we continued several minutes ; finally moving the limb in various 
directions, and adding forcible pressure upon the inside of the pro- 
jecting tibia. We then placed the leg over a double-inclined plane, 
and, securing it firmly in place, we attached a screw to the foot through 
a sandal and gaiter, and while the leg was well flexed upon the thigh, 
we renewed the extension and lateral pressure*. This was continued with 
the application of more or less power, during half an hour, meanwhile 
changing the position of the limb occasionally by varying the angle 
of the splint. Our efforts were prolonged in all more than one hour, 
when, as we had made no impression upon the bone, and the patient had 
repeatedly implored us to desist, the attempt was given over. The 
end of the tibia seemed to rest partly upon the astragalus, and the 
extension was plainly all that was demanded, but the obstacle was 
beyond doubt within the articulation, or rather between the tibia and 
fibula. 

Four weeks after, the accident, Mr. Borland walked on crutches, 
and during a year he was compelled to use a cane, but since that time, 
a period of twelve years, he has walked without any artificial support. 
Eor a year or two he felt a yielding in his ankle, as the weight of his 
body settled upon his limb ; but this gradually ceased, and for some 
years past he has walked without any halt, and seems to step as firmly 
as before the accident. The foot still inclines outwards; the tibia 
projects inwards one inch, and the broken ends of the fibula can be 
felt resting against the tibia, where they are reunited. 

Not long since I had occasion to amputate a limb for a compound 
dislocation inwards at the ankle-joint, and the possibility of this frac- 
ture was confirmed by the dissection. About one-third of the outer 
portion of the articular surface was broken off' obliquely, and the 
fragment was lying so displaced that a reduction would have been 
rendered impossible. 

Dr. Townsend, of Boston, has reported a case of compound dislo- 
cation, in which also amputation became necessary ; and, with other 
injuries, the dissection showed a fragment from the outer margin of 
the tibia, one inch and a half long, and one inch thick at its widest 



OF LOWER END OF TIBIA OUTWARDS. 



707 



part, with a very sharp point, displaced, and lying almost transversely 
over the astragalus. 1 

For a more full account of the prognosis and the general manage- 
ment of these cases subsequent to the reduction, I beg again to refer 
the reader to the chapter on fractures of the fibula ; and for my views 
in relation to the treatment of compound dislocations of the ankle-joint 
I will refer also to the chapter on compound dislocations of the long 
bones. 



§ 2. Dislocations of the Lower End of the Tibia Outwards. 

Syn. — " Outward tibio-tarsal luxation;" Malgaigne. "Dislocations of the foot in- 
wards," of others. 

The causes are the same or similar to those which are known gene- 
rally to produce dislocations in- 
wards ; only that the force of the Fi s- 287 - 
concussion or the direction of 
the rotation must have been re- 
versed. 

The external lateral liga- 
ments, peroneo-tarsal, are either 
ruptured or the lower portion of 
the fibula gives way, or both of 
these circumstances may have 
happened; while the internal 
malleolus may also yield to the 
shock and to the weight of the 
body now resting upon it. The 
nature of the accident may vary 
also in respect to the relative 
position of the articular surfaces; 
the astragalus may simply rotate 
on its inner and upper margin, 
or the tibia, with the fibula of 
course, may actually slide out- 
wards until the lower end of the 
tibia more or less completely 
abandons the upper surface of 
the astragalus. 

The modes of reduction and 
the general principles of treat- 
ment subsequently, will not 
differ from those which we have 
mentioned as suitable for dis- 
locations in the opposite direc- 
tion. The examples which have fallen under my observation are not 
numerous, but the reduction has always been easily effected. Thus, a 
man, set. 21, fell from a scaffolding, alighting upon his feet. He says 




Dislocation of the lower end of the tibia outwards. 



1 Townsend Mass. Hosp. Reports, Bost. Med. and Surg. Journ., vol. xxxiii. p. 277. 



708 DISLOCATIONS OF LOWEE END OF THE TIBIA. 

that his left foot struck the ground obliquely and upon its outer mar- 
gin. I found the fibula projecting very strongly outwards, evidently 
carrying with it the tibia; the malleolus internus was broken off, and 
the foot forcibly turned inwards. Without either flexing the leg upon 
the thigh or calling to my aid any degree of counter-extension except 
what was made by the weight of the body, I grasped the foot and drew 
upon it gently, while at the same moment I rotated the foot outwards. 
Immediately the bones resumed their places. 

In June of 1846, Henry Wilson, set. 38, consulted me in relation to 
his foot, which he said had been dislocated four weeks before. He 
had fallen upon the outside of his foot and turned it suddenly inwards, 
so that when he looked at it he found the sole presenting toward the 
opposite side. Seizing upon it with both hands, he pressed it forcibly 
outwards, and the reduction immediately took place with a snap. 
Very little soreness followed, nor was he confined to his house a single 
day. He had continued to walk about with only a slight halt in his 
gait, nor would he have thought it necessary to consult me at all ex- 
cept that the tenderness had not yet disappeared. He was not aware 
that the fibula had been broken also, until I called his attention to the 
fact. The fracture had taken place two inches above the ankle ; and 
although it was already united, the depression occasioned by its having 
fallen in somewhat toward the tibia was very plainly felt and recog- 
nized. 

§ 3. Dislocations of the Lower End of the Tibia Forwards. 

Syn. — " Forward tibio-tarsal luxations ;" Malgaigne. " Dislocations of the foot back- 
wards," of others. 

Causes. — This dislocation may be produced by a violent extension 
of the foot upon the leg ; as, for example, when, the foot being en- 
gaged under a piece of timber, the body falls backwards to the ground ; 
or when, the leg remaining fixed, a heavy weight descends upon the 
foot, the foot resting upon an inclined plane; by a blow upon the 
front of the foot ; or it may be caused by a fall upon the bottom or 
back of the tibia, or possibly, even by the toes being brought violently 
in contact with some firm body. 

Pathological Anatomy. — The displacement may be very slight, so 
that the end of the tibia is only a little advanced upon the astragalus; 
or it may be such that the tibia rests one-half upon the naviculare 
and one-half upon the astragalus, or it may even desert the astragalus 
entirely. In these latter examples, the lateral ligaments suffer more 
or less complete laceration. The fibula is generally broken on a level 
with the articulation, the malleolus internus also in some cases, and 
still more rarely a fracture occurs through the posterior margin of 
the articular surface of the tibia. 

Symptoms. — The length of the foot in front of the tibia is dimi- 
nished, while the projection of the heel is correspondingly increased ; 
the toes are turned downwards and the heel drawn upwards, and fixed 
in this position ; the end of the tibia may generally be distinctly felt 



OF LOWEE END OF TIBIA POEWAEDS. 709 

in front of the astragalus ; the extensor tendons of the toes are sharply 
defined, while the tendo-Achillis is curved forwards, and tense. 

At the regular meeting of the New York Pathological Society, 
Nov. 22, 1865, I presented a specimen obtained from the dissecting- 
room of the Bellevue Hospital College. The history of the case was 
unknown. 

Before dissection the foot was observed to be turned outwards, and 
shortened in front of the tibia, while there was a corresponding length- 
ening of the heel. The specimen, after dissection, disclosed a fracture 
of the internal malleolus half an inch above its lower end, and a frac- 
ture of the fibula a little above its lower end. The tibia was displaced 
forwards about three quarters of an inch, so that only the posterior 
half of its lower end rested upon the articular surface of the astragalus, 
and at the point of contact with the astragalus a new socket was 
formed in the tibia, concave upwards, half an inch deep, and pre- 
senting an appearance as if the posterior lip of the lower end of the 
tibia had been broken off and had become displaced upwards. It was 
supported by a broad buttress of bone. It is not certain, however, 
but that this appearance was occasioned solely by the long-continued 
pressure of the tibia upon the astragalus at this point. The fragments 
of the malleolus internus, and the lower fragment of the fibula re- 
mained attached to their upper fragments and to the two sides of the 
astragalus in their normal positions, consequently each fragment was 
inclined downwards and backwards at an angle of 45°. The lower 
fragment of the fibula was driven upwards, also, but both of the frac- 
tures were firmly united. This specimen is now in the museum of 
the Bellevue Hospital College. 

At the same meeting of the Pathological Society I reported the case 
of Mary Conlan, set. 38, admitted to Bellevue Hospital, Nov. 13th, 
1865, having been thrown three days before from a street car. She 
could give no account of the manner in which she fell. I saw her 
Nov. 16th. The limb was then much swollen and I diagnosticated a 
fracture of the lower end of the fibula. (It had been supposed to be 
a mere sprain up to this time.) The limb was directed to be wet with 
cool water and to rest upon a pillow. From this time I looked at it 
occasionally to see whether the swelling had sufficiently subsided to 
warrant the application of a splint. Nov. 20th it was examined again 
carefully by the house surgeon, Dr. Farrall, but no displacement was 
noticed. Nov. 23d I found the lower end of the tibia displaced for- 
wards, and ascertained, also, that the internal malleolus was broken at 
its base. The dorsum of the foot, measuring from the front of the 
tibia to the end of the great toe, was shortened half an inch. The heel 
was lengthened. 

There can be no doubt but in this case the dislocation occurred sub- 
sequent to the fracture, and that it was caused by the contraction of 
the gastrocnemii. I reduced the dislocation a day or two later and 
maintained it in position by the method which I shall presently 
describe. 

Dr. Yoss reported to the Society a similar case which had come 



710 



DISLOCATIONS OF LOWER EXD OF THE TIBIA. 



under his notice, and Dr. Buck remarked that he also had met with 
such examples. 1 

Treatment. — The reduction is to be attempted by flexing the leg 
upon the thigh, and making extension from the foot, while, at the 
same moment, pressure is made upon the front of the tibia and against 
the heel. When the bone begins to slide into place, the foot should 
be forcibly flexed upon the leg. A slight lateral motion or rotation 
in either direction may assist in restoring the bones to place. 



Fig. 288. 



Fig. 289. 





Dislocations of the lower end of the tibia forwards. 



In general, the dislocation has been easily reduced, but in a ma- 
jority of the examples recorded great difficulty has been experienced 
in maintaining the reduction ; and in a few cases it has been found 
impossible to do so. 

In order to maintain the reduction, the leg, flexed upon the thigh, 
should be laid on its back in a box ; and the foot supported firmly 
against a foot-piece placed at a right angle with the box. In this 
position, the weight of the leg will tend somewhat to overcome the 
action of the muscles which are disposed to displace the foot back- 
wards. Generally it will be found necessary to make additional pres- 
sure directly upon the front of the leg above the ankle ; which, in 
order that it may not prove mischievous, must be effected with some 
soft material, and must be applied over a broad surface. Perhaps 
nothing will better answer these indications than to pass a cotton band, 
six or eight inches in width, through slits or mortises in the sides of 
the box ; these slits being of a width equal to the width of the band, 
and placed at a point sufficiently below the level of the spine of the 
tibia, so that when the band is made fast underneath the box it shall 
press the leg firmly backwards. To prevent the heel from suffering 
in consequence of this pressure, it also should be supported, or sus- 
pended by another band passing underneath the heel and fastened 
above to the top of the foot-board. 



New York Journ. Med., April. 1866, p. 40. 



OF LOWER END OF TIBIA FORWARDS. 711 

Dupuytren relates the following example of this rare accident : — 

Pierre Froment, get. 33, was carrying a heavy weight upon his back, 
and had his right foot in advance, when by accident he came suddenly 
in contact with a beam placed across his path. Under the fear of 
being precipitated forwards, he made a sudden effort to throw his body 
backwards, by which he lost his balance, and fell with the point of 
the left foot inclined inwards and forwards, and his whole weight was 
thrown first on the outer side, and then on the front of the ankle- 
joint. 

On examination the leg seemed to be planted upon the middle of 
the foot ; the toes were directed downwards and the heel drawn up. 
On the instep there w r as a large bony prominence, over which the ex- 
tensor tendons of the toes were stretched like tense cords. Behind the 
joint was a deep hollow, at the bottom of which the tendo-Achillis 
could be felt forming a tense, resisting, semicircular cord, with its con- 
cavity directed backwards. The fibula was also broken ; the lower 
end of the lower fragment remaining attached to the foot, while the 
upper end of the same fragment was carried forwards by the displace- 
ment of the tibia, so that it lay nearly horizontally, with its broken 
extremity directed forwards. 

Dupuytren directed one assistant to fix the leg, and a second to 
make extension from the foot, while Dupuytren himself, standing on 
the outer side of the limb, forced the heel forwards and the tibia back- 
wards. The first attempt succeeded partially, and the second com- 
pleted the reduction. The limb was then placed in the apparatus 
employed by this surgeon for a fractured fibula, which we have before 
described, and laid on its outer side in a semiflexed position. The 
patient recovered rapidly, and in little more than a month he was able 
to walk. 1 

But such fortunate results have not usually been observed ; indeed 
Dupuytren encountered much more serious difficulties in two other 
cases which came under his own notice, one of which he has himself 
recorded. This was in the person of a woman aet. 48, who was brought 
to the Hotel Dieu in 1815, the accident having just happened from a 
slip in going down stairs. The fibula was broken, and also a frag- 
ment was broken from the tibia. The house surgeon reduced the 
bones and placed the limb in the ordinary apparatus for broken legs, 
but on the following day Dupuytren found them reluxated, and laid 
the limb on his own splint, but the pressure requisite to keep the tibia 
in place soon induced sloughing, ulceration, and abscesses, and after 
four months' treatment, during which time the tibia had been repeat- 
edly displaced, she left the hospital able to use her limb, but with a 
certain amount of incurable deformity. 2 

Malgaigne mentions the third example as having been seen by 
himself in Dupuytren's service in 1832, in which case the attempt to 
maintain the reduction by a tourniquet resulted in gangrene and 
finally the death of the patient. 3 Earle lost a patient after amputation 

1 Dupuytren. Injuries and Dis. of Bones. London ed., p. 278. 

2 Op. cit., p. 27o. 3 Malgaigne, op. cit.. p. 1044. 



712 



DISLOCATIONS OF LOWER END OF THE TIBIA. 



made on the eighth day. The tibia could not be kept in place, and 
the amputation became necessary on account of the final protrusion 
of the bone through the integuments, which had sloughed. 1 



§ 4. Dislocations of the Lower End of the Tibia Backwards. 

Syn. — "Backward tibio-tarsal luxations;" Malgaigne. "Dislocations of the foot 
forwards," of others. 

More rare even than the dislocations forwards, Malgaigne has, never- 
theless, succeeded in collecting five examples. 

They appear to have been produced generally by a cause, the re- 
verse of that which we have seen to produce so often the preceding 
dislocation. Thus while the dislocation forwards is produced most 
frequently when the foot is in violent extension, this dislocation has 
occurred in at least two or three cases, when the foot was forcibly 
flexed upon the leg. 

The symptoms are strongly marked and characteristic. The length 
of the foot from the tibia to the ends of the toes is increased one inch 
or more ; the heel being correspondingly shortened, or rather wholly 
obliterated ; a portion of the articulating surface of the astragalus 
may be distinctly felt in front of the tibia ; the posterior surface of 
the tibia touches the tendo- Achillis ; the leg is shortened, and the mal- 
leoli approach the sole of the foot. 

In most cases one or both of the malleoli have been broken ; and 
E. W. Smith, who has reported one of the examples alluded to, be- 
lieves that the dislocation is never complete. 



Fig. 290. 



Fig. 291. 





Dislocations of the lower end of the tibia backwards. 

Eeduction should be attempted by a method similar to that which 
has been recommended in all the other dislocations of the ankle ; only 
with such modifications as the peculiarities of the case must necessa- 
rily suggest. 



Malgaigne, op. cit., p. 1044. 



UPPEK EXD OP THE FIBULA FORWARDS. 713 



CHAPTEE XX. 

DISLOCATIONS OF THE UPPER END OF THE FIBULA. 

Syn. — " Luxations of tlie superior peroneo-tibial-articulation ;" Malgaigne. 

Surgeons have frequently described a condition of the peroneo- 
tibial articulation, in which the ligaments have become relaxed, giving 
a preternatural mobility to the head of the bone. It is also not unfre- 
quently displaced upwards, in consequence of an oblique fracture of 
the tibia. I have myself seen several examples of both these acci- 
dents ; but simple traumatic dislocations, which can only occur for- 
wards or backwards, are very rare. 

§ 1. Dislocations of the Upper End of the Fibula Forwards. 

Malgaigne has collected three examples of this luxation, uncom- 
plicated with any other accident, and not apparently due to any ab- 
normal condition of the ligaments, two of which at least seemed to 
have been produced by the violent action of the muscles which are 
attached to the anterior face of the fibula. The third example, re- 
ported by Thompson, in the London Lancet, 1 permits a doubt as to 
whether the displacement was occasioned by muscular action, or by 
a direct blow upon the part. 

The signs which characterize the anterior luxation are the absence 
of the head of the fibula in its natural position, and its presence in 
front, near the ligamentum patellae ; the altered direction of the biceps 
flexor cruris muscle ; and, in one case, considerable deformity in the 
shape and position of the leg has been observed. 

Thompson and Jobard were unable to accomplish the reduction 
while the leg was extended upon the thigh, but succeeded readily 
after having flexed the leg. On the other hand, Savournin succeeded, 
with the leg extended, but with the foot flexed upon the leg. Mal- 
gaigne, to whom I am indebted for these observations, thinks that 
flexion of the leg, combined with flexion of the foot, would render the 
reduction more easy. 

In whatever position the limb is placed, the surgeon must rely 
chiefly upon forcible pressure made with the fingers against the front 
and upper portion of the displaced bone. 

J. E. Hawley, of Ithaca, N. Y., a distinguished practitioner, and late 
Prof, of Surgery in the Geneva Medical College, has furnished me 
with a brief account of a case which came under his own observation. 

1 Op. cit., 1850, vol. i. p. 385. 

46 



714 DISLOCATIONS OF THE UPPER END OF FIBULA. 

On the 29th of March, 1854, Bambak, while vaulting upon the 
parallel bars in a gymnasium, unintentionally made a complete somer- 
set, and fell with his right foot upon the edge of a plank. Dr. Hawley, 
who was immediately called, found his right leg semi-flexed and im- 
movably fixed. The head of the fibula was plainly felt in front of 
its natural position, near the ligamentum patellae. The patient was 
suffering the most intense pain. Extension and counter-extension 
were made, and while the doctor was pressing with both of his thumbs 
upon the head of the fibula, it went into its place with an audible snap, 
The relief was instantaneous. Complete rest was observed for a few 
days, while cooling lotions were constantly applied, and within a week 
he was able to attend to his usual duties. 



§ 2. Dislocations of the Upper End of the Fibula Backwards. 

Sanson has recorded one example, in which the passage of the 
wheel of a carriage across the upper part of the leg, precisely on a 
level with the peroneo-tibial articulation, ruptured the ligaments which 
bind the fibula to the tibia, and caused a displacement which, however, 
seems to have been spontaneously overcome. Nevertheless there re- 
mained a preternatural mobility, permitting the fibula to be pushed 
easily backwards or forwards upon the tibia. 

I have found only two other cases of backward dislocation, one of 
which is related by Dubreuil. A man, aet. 62, in order to save him- 
self from falling sprang suddenly, with his right leg in a position of 
extreme abduction, and at the same moment he experienced a severe 
pain in the region of the peroneo-tibial articulation. The head of the 
fibula was found to be thrown backwards, and formed under the skin 
a marked prominence ; the foot was drawn outwards, and the whole 
outside of the limb became cold and numb. Dubreuil flexed the leg 
moderately, and pressing the head of the fibula from behind forwards, 
the reduction was easily effected. On the following day, the limb 
having been straightened, the dislocation was found to be reproduced. 
It was again replaced, and the knee covered with a leather cap, secured 
moderately tight. After twelve days of complete rest, the knee was 
moved gently, and on the seventeenth day the patient walked with 
the help of a cane. For some time the leg had a tendency to incline 
outwards; but in about three months the cure was perfectly esta- 
blished. 1 

It is probable that in this case the dislocation resulted from the 
violent action of the biceps flexor cruris. Such at least is the opinion 
of both Dubreuil and Malgaigne, and I see no reason to question the 
correctness of their theory. 

The other example has been reported by Dr. Jos. G. Bichardson, 
resident Physician to the Pennsylvania Hospital. John Dixon, set. 9, 
fell five feet and struck upon the outside of the left knee. When ad- 
mitted to the Hospital, the leg was partly flexed and the toes a little 
everted, and he was unable to flex or extend the limb completely. 

1 Malgaigne, op. cit., torn. ii. p. 386. 



DISLOCATIONS OF THE ASTKAGALUS. 715 

The head of the fibula was seen three-quarters of an inch behind its 
natural position, and the biceps was felt distinctly, attached. There 
was no other lesion. The reduction was easily accomplished by press- 
ing with the fingers, upon the inner and back part of the fibula, 
thrusting it outwards and forwards. A compress and bandage were 
applied, and the limb placed at rest. The reduction continued com- 
plete, and after a few days he was permitted to use the limb. 1 



CHAPTEE XXI. 

DISLOCATIONS OF THE INFERIOR P ERO NEO-TIBIAL 
ARTICULATION. 

Nelaton" relates the only example of a simple luxation of this ar- 
ticulation of which we have any information. The patient who was 
the subject of this accident, presented himself at the hospital under the 
care of M. Gerdy on the thirty-ninth day after the accident, which had 
been occasioned by the passage of the wheel of a carriage obliquely 
across the leg in such a manner as to push the malleolus externus 
directly backwards. The lower end of the fibula was in almost direct 
contact with the outer margin of the tendo-Achillis; the outer face of 
the astragalus, abandoned by the fibula, could be distinctly felt in 
nearly its whole extent ; the foot preserved its natural position ; and 
he could walk pretty well, only that he was obliged to step with some 
care. M. Gerdy believed that the bone was too firmly fixed in its new 
position to be moved, and therefore made no attempt at reduction. 



CHAPTEE XXII. 

TARSAL LUXATIONS. 
§ 1. Dislocations op the Astragalus. 

Malgaigne, who speaks also of luxations "sub-astragaloid," has 
thought proper to call the dislocations which we now propose to 
consider "double dislocations of the astragalus." In the variety first 
named, the astragalus retains its connections with the tibia, but sepa- 
rates from the scaphoid bone, while its relations to the calcaneum are 
only slightly disturbed. This we prefer to regard as one of the many 
varieties of tarsal luxations, and shall appropriate to it no specific 

1 Richardson, Amer. Journ. Med. Sci., April, 1863. 



716 



TAESAL LUXATIONS. 



appellation, except to designate it as astragalo-scaphoid, or astragalo- 
calcaneo-scaphoid, according as more or less of the several articula- 
tions are disturbed. 

In the second named variety, called by Malgaigne a "double" luxa- 
tion, and which constitutes the subject of this chapter, the astraga- 
lus abandons all the articular surfaces against which it is naturally 
applied and thrusts itself out from between the tibia, fibula, cal- 
caneum, and scaphoides; so that it may be said to have suffered a 
triple or quadruple rather than a "double" dislocation, as is implied 
by the nomenclature adopted by Malgaigne. This we choose to regard 
as the only true dislocation of the astragalus, and as such we propose 
to designate it by the simple term "dislocation of the astragalus." 

The astragalus may be dislocated forwards, outwards, inwards, back- 
wards ; or it may be dislocated obliquely in either of the diagonals 
between these lines; it may be simply rotated upon its lateral axis 
without much, if any, lateral displacement ; and, finally, it has been 

occasionally driven be- 



Fig. 292. 




Dislocation of astragalus outwards. Anatomical relations. 



tween the tibia and fibu- 
la, tearing away the in- 
termediate ligaments,and 
generally fracturing one 
or both bones of the leg. 
Causes. — The causes 
which have been found 
chiefly operative in the 
production of this dislo- 
cation are very much the 
same as those which pro- 
duce,under other circum- 
stances, a dislocation of 
the lower end of the tibia. 
Thus, a fall from a height upon the bottom of the foot, accompanied 
with a violent abduction, adduction, flexion, or extension, may deter- 
mine a dislocation of the astragalus inwards, outwards, backwards, or 
forwards. Sometimes it is accomplished by a mere wrenching and 
twisting of the foot in machinery, or in the wheel of a carriage, or by 
being caught between two irregular bodies. It may be produced also 
by a direct blow. 

Symptoms. — The great prominence occasioned by the displacement 
of the bone in either of these several directions, accompanied gene- 
rally with more or less lateral deviation of the foot, is alone sufficient 
to indicate the true nature of the accident. In some cases, also, the 
foot is forcibly flexed or extended ; the leg is shortened in conse- 
quence of the tibia having fallen down upon the calcaneum ; the super- 
incumbent skin and tendons are rendered tense ; blood is effused, and 
swelling speedily occurs. In the backward dislocation, the position 
of the foot is not much changed, but the tibia being slightly carried 
forwards, the length of the dorsal aspect of the foot is proportionably 
diminished. 

Such are the symptoms which plainly enough indicate the dislo- 



DISLOCATIONS OF THE ASTEAGALUS. 



717 



cation in the most simple cases ; but in a majority of the examples 
which have been seen, the integuments have been more or less exten- 
sively torn, exposing to the eye at once the naked bone, and thus 
removing all chance of error in the diagnosis. 

Norris mentions a case, seen by Hammersley, in which the astra- 
galus was thrown completely out, and was subsequently found in the 
earth where the patient had received his injury. Inflammation, gan- 
grene and tetanus supervened, and the patient died on the seventh day. 1 



Fig. 293. 



Fig. 294. 





Simple dislocations of the astragalus outwards. 



Compound dislocation of the astragalus inwards. 



Prognosis. — It will be readily understood that nothing short of very 
great violence could disturb and completely break up the connections 
of a bone so compactly and firmly seated as is the astragalus, and 
that aside of any unusual complications, under the most favorable 
circumstances, intense inflammation must naturally be anticipated; 
and with few exceptions this has actually taken place. Even when 
reduction has been promptly and easily effected, inflammation, gan- 
grene, and death have sometimes speedily ensued. But more often the 
reduction has been found to be exceedingly difficult or impossible, and 
complete removal of the bone or amputation has been immediately 
demanded. 

In a limited number of cases, on the other hand, the bone has been 
easily reduced, and recovery has taken place with a tolerably useful 
limb ; or resection has been practised with an equally favorable result ; 
in still other cases the bone has been left protruding, and the patient 
has finally recovered so far as to be able to walk again, but in such 



1 Norris, Anier. Journ. Med. Sci., 1837, p. 383. 



718 TARSAL LUXATIONS. 

a crippled condition as to render the achievement a very doubtful 
triumph of conservative surgery. 

ISTorris, of Philadelphia, relates the following case, illustrating the 
imminent danger to which even the life of the patient may be ex- 
posed in those examples which are apparently the most simple. 

William Summerill, set. 30, was admitted to the Pennsylvania 
Hospital on the twenty-sixth of September, 1831. An hour previous, 
while descending a ladder, he slipped and fell in such a manner as to 
throw the entire weight of his body upon the outer part of his left 
foot. The foot was turned inwards and nearly immovable ; a slight 
depression existed immediately below the lower end of the tibia, and 
there was a hard rounded projection on the outer part of the foot a 
little below and in front of the extremity of the fibula ; the skin over 
this projection was not broken or excoriated, but reddened ; there was 
no fracture of either bone of the leg. 

The symptoms rendered it plain that the astragalus was dislocated 
forwards and outwards. Dr. Barton, under whose care the patient 
was received, proceeded soon after to make attempts at reduction. 
The muscles of the leg were relaxed as much as possible, and exten- 
sion made from the foot by seizing the heel and front part of the foot 
while an assistant made counter-extension at the knee. The bone was 
also pushed inwards toward the joint by the surgeon. These efforts 
were continued for a considerable time, but had no effect in changing 
the position of the bone. 

Six hours afterwards, Drs. Harris and Hewson being in consulta- 
tion, the attempt was again made to accomplish the reduction, but 
without success ; and the surgeons immediately proceeded to excise 
the bone. 

An incision was made parallel with the tendons, commencing a 
short distance above the projection and extending down far enough to 
expose fairly the astragalus and its torn ligaments. The bone was 
then seized with the forceps and easily removed after the division of 
a few ligamentous fibres that continued to connect it with the adjoin- 
ing parts. Yery little bleeding occurred, only two small arteries re- 
quiring the ligature. 

After removal, it was discovered that about one half of the surface 
which plays in the lower end of the tibia had been fractured, and that 
it remained firmly attached to the extremity of that bone. No at- 
tempt was made to remove this fragment ; but the joint being care- 
fully sponged out, the sides of the wound were brought together and 
closed by sutures, adhesive straps and a roller ; after which the foot, 
placed in its natural position, was laid in a fracture-box. 

On the fifth day a slough began to form upon the outside of the 
foot, which was followed by suppuration at other points, and on the 
thirteenth day an opening was made to evacuate the pus near the 
malleolus intern us. At the end of about eight weeks the fragment 
of the astragalus which had been suffered to remain, was found to be 
carious, and it was removed ; the heel also had ulcerated from pres- 
sure, and several other bones of the tarsus were discovered to be ca- 
rious. Fifteen months later, this poor fellow was still in the hospital 



DISLOCATIONS OF THE ASTRAGALUS. 719 

suffering from hectic, with extensive disease in the bones of the tar- 
sus and ankle-joint. Finally, amputation of the leg was practised by 
Dr. Barton, a few days after which he died. 1 

Norris mentions also two examples of simple dislocation of the as- 
tragalus at the Pennsylvania Hospital which came under the obser- 
vation of Dr. Barton, in both of which the bone was left unreduced. 
In one case inflammation and sloughing soon effected a complete ex- 
posure of the protruding bone, but after a time the skin cicatrized. At 
the end of five months the patient walked and had good use of the 
joint, though great deformity of the foot existed, and he continued to 
be subject to ulceration of the newly -formed skin on its outer part. 
In the other case gangrene supervened soon after the accident, and 
the patient died. 

Norris adds that "the late Professor Wistar removed the astragalus 
in a case of compound dislocation, and the patient was cured with 
some motion at the joint." 

Dr. Alexander Stevens, of New York, made the same operation in 
a case of compound dislocation, and after several months, he affirms 
that the patient u has recovered with very trifling deformity of the 
foot, and with a flexible joint. He walks with very slight lameness." 2 

I am indebted to Dr. B. H. Hart, of Marietta, Ohio, for an account 
of the following case, and for the specimen, which has, also, kindly 
been put in my possession. 

In June, 1853, Thomas Williams was thrown from his carriage, 
alighting upon his left foot and causing a compound dislocation of the 
ankle joint. Dr. Hart was immediately called, and found the bones 
of the leg thrust through the integuments on the outside, the malleo- 
lus internus broken, and the astragalus partially dislocated. After 
enlarging the opening in the integuments with a pocket knife, the 
Dr. was able to reduce the dislocated bones to place. It must be 
mentioned that this man weighed 225 lbs., and that in his fall he de- 
scended a precipice or bank 30 feet in height. Soon after the reduc- 
tion the patient had two severe convulsions, which were arrested by 
bleeding and opiates, and never returned. Cool lotions were applied 
to the limb ; and on the sixth day erysipelas supervened and extended 
nearly to the body. The erysipelas continued about nine days. Ex- 
tensive suppuration throughout the joint resulted, and some fragments 
of bone came away, and on the thirty-third day Dr. Hart removed 
without the aid of the knife the entire astragalus. In three months 
the patient walked upon crutches, and in eleven months he could walk 
well without a staff) a slight motion having been preserved in the 
ankle joint. 

The dislocations backwards, of which seven examples only have 
been recorded, have all with but one exception been left unreduced ; 
yet in at least four instances the patients have recovered with pretty 
useful limbs. Such was the fact with Liston's and Lizar's patients, 
and also with Mr. Phillips' two cases, to all of which I shall again 

1 Norris, Amer. Journ. Med. Sci., Aug. 1837, p. 378. 

2 Stevens, North Amer. Med. and Surg. Journ., Jan. 1827, p. 200. 



720 TABS XL LUXATIONS. 

refer. It must be noticed, however, that in each of the cases men- 
tioned as followed by a successful termination without reduction, the 
dislocations were simple. 

Turner, of Manchester, has reported one example of compound 
luxation outwards and backwards, in which, finding himself unable 
to effect reduction, he removed the astragalus with a tolerably success- 
ful result. 1 Finally a case was presented in one of the London hos- 
pitals in 1839, of a dislocation inwards and backwards, which was 
reduced in about ten minutes, by extension accompanied with lateral 
pressure. 2 

Treatment. — Various attempts have been made by surgical writers 
to determine the line of treatment which should be adopted in these 
unfortunate cases, but with very unsatisfactory results, since they are 
far from having arrived at similar conclusions, nor have they been 
able always to settle the question definitely for themselves. The diffi- 
culty consists in the multiplicity, and lack of uniformity in the com- 
plications which attend these accidents, rendering it impossible to 
establish a classification upon which an uniform treatment may be 
safely based. There are certain principles, however, which seem to 
be sufficiently settled to allow of an authoritative announcement; 
these may be briefly stated as follows : If the dislocation is simple, 
reduce the astragalus immediately, provided this is possible. If the 
luxation is complete, and it cannot be reduced, even partially, proceed 
at once to resection or to amputation. In compound dislocations, re- 
section or amputation affords the only safe resource. In all cases the 
inflammation is likely to be intense, in order to prevent which com- 
plication the surgeon must be unremitting in his use of the appropri- 
ate remedies. 

Out of eighteen cases of complete excision of the astragalus, collected 
by Turner, fourteen made good recoveries, and in only one of these 
fourteen was there anchylosis. 

These several points we shall proceed to illustrate a little more, 
fully. 

In a recent simple luxation of the astragalus forwards, the leg 
should be flexed to a right angle with the thigh, and for the purpose 
of making extension, one assistant should take hold of the foot with 
both hands in the same manner that a servant draws a boot, that is, 
with the right hand grasping the heel, and the left placed upon the 
dorsum of the foot near the toes. A second assistant should seize the 
lower part of the thigh in order to make counter-extension, while the 
surgeon presses with the ball of his hand against the head of the as- 
tragalus, upwards and backwards. If these simple measures fail, the 
pulleys ought to be employed as a substitute for the hands in making 
extension. In applying the extension, the toes must be kept well 
down, and occasionally the foot should be moved gently from one side 
to the other. 

An oblique dislocation must be reduced, if possible, to an anterior 

1 Turner, Trans. Provin. Med. and Surg. Journ., vol. ix. Essay on Disloc. of As- 
trag. with nearly fifty cases. 

2 London Lancet, vol. ii.'p. 559. 



DISLOCATIONS OF THE ASTRAGALUS. 721 

luxation, before an attempt is made to carry the head of the bone back 
to its place, as by this mode the reduction will be greatly facilitated. 

Lateral luxations may be reduced by the same means ; but if the 
astragalus is dislocated outwards the foot must be held forcibly ad- 
ducted during the extension, and if it is dislocated inwards, the foot 
must be held strongly in the opposite direction. 

Lizars says that he has seen one case of backward luxation, and 
that all attempts at reduction were unavailing. The limb was, how- 
ever, preserved, and proved to be useful. 1 Liston was equally un- 
successful in a case which came under his notice. 2 Phillips has 
reported two cases, in neither of which was the reduction accom- 
plished. 3 ISTelaton has seen a compound dislocation which he could 
not reduce. 4 Mr. Erichsen, however, who admits that when dislocated 
backwards it has not hitherto been reduced, declares that the surgeons 
at University Hospital have succeeded in one case recently, in which 
both the tibia and fibula were broken also. 5 Mr. Erichsen suggests 
also that in case of a failure by the ordinary means, we should resort 
to a subcutaneous section of the tendo-Achillis. Mr. Williams, of 
Dublin, in a similar case, which had been left unreduced, was obliged 
finally to extract the bone, in consequence of the integuments having 
sloughed. 6 

Compound dislocations, and such as are otherwise complicated, 
demand of the surgeon immediate amputation, or exsection, the latter 
of which ought to be preferred whenever the condition of the limb 
encourages a reasonable hope that the foot may be saved. 

Dr. Grant, of Canada, has recently reported a case, however, of suc- 
cess after reduction of a compound dislocation of this bone. The man 
was 35 years old, and in good health. Immediately after the accident 
the astragalus was found completely dislocated forwards, and lying 
with its long axis placed transversely, so that the anterior extremity 
protruded through the integuments one inch on the outer side of the 
foot. There was no fracture. The first attempt at reduction, by ex- 
tension and pressure, failed; but in the second attempt moderate 
pressure, without extension, was successful. Suppuration ensued, and 
continued two months. At the end of eight months he walked with- 
out a cane : and at the date of the report the ankle was in all respects 
perfect. 7 

When exsection is practised, and the bone is found to be broken, 
as it often is, all the fragments should be carefully removed, since 
they are certain to become necrosed if left in place. Nor ought the 
surgeon to hesitate to lay open freely the tissues in every direction, in 
order that he may accomplish this purpose; even the tendons lying 
over the protruding bone may be sacrificed unhesitatingly, since after 

1 Lizars, System of Practical Surg., Edinburgh ed., 1847, p. 161. 

2 Liston, Elements of Surgery, vol. iii. p. 348. 

3 Phillips, Lond. Med. Gaz., vol. xiv. p. 596. 

4 Nelaton, Pathologie Chirurg., t. ii. p. 482. 

5 Erichsen, Science and Art of Surg., Amer. ed., 1859, p. 270. 
5 Williams, Erichsen, op. cit., p. 271. 

' Grant, Canada Med. Journ., Oct. 1865. 



722 TAESAL LUXATIONS. 

having been so severely bruised, stretched, and lacerated, they are 
pretty certain to slough. Indeed, the more freely the tissues are 
divided over the bone, the less will be the danger of inflammation, 
and the safer will be the life and limb of the patient. 

In addition to the examples already cited of compound dislocation 
in which the astragalus was removed, the following, reported by Dr. 
W. A. Gillespie, of Ellisville, Ya., will also illustrate the occasional 
value of exsection in these severe accidents. 

Mrs. A., aged about fifty years, fell from a horse on the 23d of May, 
1833, dislocating both ankles. The luxation of the right foot was 
accompanied with a luxation of the astragalus outwards, which pro- 
jected through a very large wound in the integuments, and its trochlea 
was placed at an angle of about 45° with its natural position. Early 
on the following day it was removed by severing its few remaining 
connections, and the wound was immediately closed by stitches, ad- 
hesive plasters, and light dressings. From the moment of the receipt 
of the injury, and for several days afterwards, she suffered excruciating 
pain in the limb, and on the third day tetanus was apprehended, but 
its full accession was prevented by the free use of opiates. The limb 
was suspended in N. R. Smith's fracture apparatus; and as gangrene 
with hectic fever soon threatened the life of the patient, fermenting 
poultices were diligently applied, and the patient was sustained by 
wine, bark, and other tonics. Two months after the injury was re- 
ceived, the date at which the report is given, the wound had entirely 
healed, and her complete recovery was regarded as certain. 1 Many 
other similar examples have been reported by foreign surgeons. 

One word more with regard to the treatment of the wound after 
excision. A considerable experience in accidents and wounds of this 
class, that is, wounds accompanied with great contusion and lacera- 
tion, has convinced me that the practice of closing the surface with 
sutures, adhesive plasters, bandages, &c, is eminently pernicious. 
The effusions which must necessarily occur, and which indeed we 
think ought to occur, are thus imprisoned beneath the skin, giving 
rise to swelling, pain, inflammation, and finally suppuration or slough- 
ing. It is far better, in our opinion, to leave the wound open, covering 
it only with cloths constantly kept moist with cool water. For this 
latter purpose some mode of irrigation is preferable, as being more con- 
stant and uniform. To those who have never adopted this treatment 
of contused wounds, or of wounds generally, we would recommend an 
early trial, feeling confident that they will never have occasion to 
regret the experiment. 

§ 2. A straqalo-Calcaneo- Scaphoid Dislocations. 

It is perhaps quite as common for the astragalus to be dislocated 
from the scaphoid bone and calcaneum, while it retains its connections 
with the tibia, as to be luxated from all these bones at the same time. 
This astragalo-calcaneo-scaphoid dislocation is that which Malgaigue 

1 Gillespie, Amer. Journ. Med. Sci., Aug. 1833, p. 552. 



ASTKAGALO-CALCANEO-SCAPHOID DISLOCATIONS. 723 

has termed " sub-astragaloid." Produced by the same causes which 
determine true dislocations of the astragalus, it may occur in the same 
directions, and is liable to the same complications ; nor will either the 
prognosis or treatment differ essentially from that which is recognized 
and established in the other accident. 

As in dislocations proper of the astragalus, so also in this accident, 
opposite results have occasionally followed from similar modes of 
treatment. Thus, Dr. Detmold, of New York, stated in 1856 to the 
New York Academy of Medicine, that he had recently met with a 
dislocation of the astragalus, in which the bone retained its proper 
relations with the tibia, but not with the bones of the tarsus. The 
patient had fallen from a wagon and caught his foot in the wheel. 
Dr. Detmold made extension with pulleys, but could not effect the 
reduction. Subsequently he was obliged to remove the astragalus on 
account of the suppuration which followed and the consequent exposure 
of the bone. The wound did not heal kindly, and at length amputation 
of the leg became necessary. 

Dr. Detmold concludes, from this example and others which have 
come to his knowledge, that if a similar case were to present itself to 
him again, he would amputate at once. 1 

The following case, reported by Dr. Thomas Wells, of Columbia, 
S. C, is of unusual interest, as illustrating the danger of leaving the 
bone displaced, and also the benefit which may, even under the most 
unfavorable circumstances, result from its final removal. 

Doctor S., set. 30, was riding in an open carriage, some time during 
the year 1819, when his horses became frightened and ran, and in 
leaping from his vehicle he struck upon his left foot, dislocating the 
astragalus from its junction with the scaphoid bone, upwards and 
slightly outwards. Several medical gentlemen made violent efforts to 
reduce the bone, but without effect. Inflammation and suppuration, 
accompanied by a high fever, soon followed, and the head of the 
astragalus becoming carious, protruded through the skin. On the 
18th of August, about seven months after the injury was received, he 
was still suffering from a copious discharge, pain, swelling, and general 
irritative fever, and it was determined to excise the bone ; which was 
accordingly done by enlarging the wound and detaching its loose 
connections with the adjacent tissues. The astragalus extracted left a 
frightful wound, the foot seeming to be nearly separated from the leg. 
A hollow splint was adjusted to the inside of the foot and leg, so as to 
preserve the limb perfectly steady and in a proper direction ; simple 
dressings were applied, and an anodyne administered internally. No 
accidents followed, and at the end of September the wound was healed, 
and the swelling of the parts had entirely subsided. One year after 
the operation, he walked without the least difficulty ; the ankle being 
then " perfectly sound." The leg was shortened about one inch, and 
this deficiency was supplied by a thick heel upon his shoe. 2 

Examples might be cited illustrative of the value of early exsection 

1 Detmold, New York Journ. Med., May, 1856, p. 383. 

2 Wells, Amer. Joum. Med. Sci., May, 1832, p. 21. 



724 TAKSAL LUXATIONS, 

where reduction could not be accomplished ; but after what has 
already been said upon the subject of dislocations of the astragalus, 
we shall not regard any farther reference as either necessary or useful. 
If other principles of treatment are to govern the surgeon than those 
which we have already laid down, they cannot here be stated. They 
are among those unwritten rules whose existence we cannot always 
recognize until the case arises upon which they may apply. Yet in 
the exigency supposed they are as clearly defined, and as imperative, 
in the mind of the clever surgeon, as any of those laws which have 
been made the subjects of special record. 



§ 3. Dislocations or the Calcaneum. 

The calcaneum may, as a consequence of a fall upon the heel, or 
of a direct blow, be dislocated outwards from the astragalus alone, or 
upwards and outwards from the cuboid bone at the same time. It 
has been found also at the same moment dislocated outwards from the 
astragalus, and inwards upon the cuboid bone. 

Chelius says he has seen an old dislocation of the calcaneum, pro- 
duced in early life by pulling off a boot, from which there finally 
resulted a degeneration like elephantiasis of the leg, rendering ampu- 
tation necessary. 1 

Mr. South remarks in his Notes to Chelius, that the two cases of 
dislocation outwards of this bone, mentioned by Sir Astley Cooper, 
were from his (South's) Notes (cases 199 and 200). In the first case, 
that of Martin Bentley, occasioned by the falling of a heavy stone 
upon his foot, the integuments were not broken, and the position of 
the foot resembled a varus. "The dislocation was easily reduced, 
having bent the thigh and knee on the body and fixed the leg, by 
laying hold of the metatarsus and of the tuberosity of the heel-bone, 
and drawing the foot gently and directly from the leg, during which 
extension Cline put his knee against the outside of the joint, and the 
foot being pressed against it, the heel and the navicular bone readily 
slipped into their place, and- the deformity disappeared." He was 
discharged from the hospital in five weeks, "having the complete use 
of his foot." 

In the second case, the dislocation, produced also by the fall of a 
stone upon the foot, was compound, and the patient, Thomas Gilmore, 
having been brought into St. Thomas's Hospital, the reduction was 
effected by extending the foot, and rotating it outwards. Six months 
after, when he left the hospital, he was able to walk pretty well with 
a stick, 

§ 4. Middle Tarsal Dislocations. 

The scaphoid and cuboid bones may be dislocated from the astra- 
galus and calcaneum, constituting what is termed, by Malgaigne, a 
middle tarsal dislocation. It is probable that to some extent the same 

1 Chelius, System of Surg., Amer. ed., vol. ii. p. 354. 



DISLOCATIONS OF THE OS SCAPHOIDES. 725 

thing has occurred in many of those cases which are reported as sim- 
ple dislocations of the astragalus, or as dislocations at the astragalo- 
scaphoid articulation ; but it occurs also occasionally in a degree so 
perfect and complete as to leave no doubt as to the true nature of the 
disjunction, and to entitle it to a separate consideration. 

Mr. Liston mentions the case of a boy, set. 14, who fell from a height 
of forty feet, striking, apparently, upon the extremity of the foot. 
The scaphoid and cuboid bones were found to be displaced upwards 
and forwards, so that the foot was shortened about half an inch, and 
had a clubbed appearance. No attempt was made to reduce the bones, 
and he left the hospital in three weeks, able to stand on the foot. 1 Sir 
Astley Cooper has recorded in more detail a similar example. A man, 
working at the Southwark bridge, London, received upon the top of 
his foot a stone of great weight. He was immediately carried to Guy's 
Hospital, and his condition is described as follows : " The os calcis 
and the astragalus remained in their natural situations, but the fore 
part of the foot was turned inwards upon the bones. When examined 
by the students, the appearance was so precisely like that of a club- 
foot, that they could not at first believe but that it was a natural defect 
of that kind," but upon the assurance of the man, that previously to 
the accident his foot was not distorted, extension was made, and the 
reduction was effected. He was discharged from the hospital in five 
weeks, having the complete use of his foot. 2 

§ 5. Dislocations of the Os Cuboides. 

According to Piedagnel, quoted by Chelius, the cuboid bone may 
be dislocated upwards, inwards, and downwards, but Malgaigne affirms 
that he has found no case recorded in which the dislocation has oc- 
curred alone, or unaccompanied with a dislocation of one or more of 
the other tarsal bones. 



§ 6. Dislocations of the Os Scaphoides. 

Burnett has seen a luxation of the scaphoid bone in which its con- 
nections with the astragalus were undisturbed, while at the same time 
it was completely separated from the cuneiform bones. By strong 
pressure exercised during several minutes, the os scaphoides was 
made to fall into its place. The dislocation was compound, yet the 
wound healed rapidly, and in a short time the recovery was almost 
complete. 3 

Several examples are recorded of a true luxation of the os sca- 
phoides, in which the bone had abandoned both the astragalus on the 
one hand, and the cuneiform bones on the other. 

Piedagnel mentions a case in which the scaphoid bone was broken 
longitudinally, and its internal fragment, constituting the largest por- 

1 Practical Surgery, also London Lancet, vol. xxxvii. p. 133. 

2 Sir A. Cooper on Disloc, &c, London ed., 1823, p. 376. 

3 Burnett, Loud. Med. Gazette, 1837, vol. xix. p. 221. 



726 TARSAL LUXATIONS. 

tion, was displaced inwards through a tegumentary wound. He was 
unable to effect reduction, and was compelled to amputate the foot. 1 

Walker has reported the first example of luxation forwards, occa- 
sioned by jumping upon the ball of the foot. The bone formed a 
marked projection upon the top of the foot, and a corresponding de- 
pression existed below. An attempt was first made to accomplish 
the reduction by simple pressure with the thumbs; but this having 
failed, the surgeon bent the extremity of the foot forcibly downwards, 
and by continuing to press upon the os scaphoides, it fell into its posi- 
tion easily and with a distinct click. In about three weeks the patient 
was able to walk with only a slight halt, and no deformity remained. 2 

§ T. Dislocations of the Cuneiform Bones. 

The cuneiform bones may be luxated partially, and without having 
separated from each other, of which two or three examples are re- 
corded ; or, which is more common, the cuneiforme internum may be 
luxated alone. Says Sir Astley Cooper: "I have twice seen this 
bone dislocated ; once in a gentleman who called upon me some weeks 
after the accident, and a second time in a case which occurred in Guy's 
Hospital very lately. In both instances the same appearances pre- 
sented themselves. There was a great projection of the bone inwards, 
and some degree of elevation, from its being drawn up by the action 
of the tibialis anticus muscle ; and it no longer remained in a direct 
line with the metatarsal bone of the great toe. In neither case was 
the bone reduced; the subject of the first of these accidents walked 
with but little halting, and I believe would in time recover the use of 
the foot, so as not to appear lame. The cause of the accident was a 
fall from a considerable height, by which the ligament was ruptured 
which connects this bone with the os cuneiforme, and with the os 
naviculare. The second case, which was in Guy's Hospital, my ap- 
prentice, Mr. Babington informs me, happened by the fall of a horse, 
and the foot was caught between the horse and the curb-stone." 3 

In a case of compound luxation seen by Mr. Key, reduction was 
effected, and in two months the cure was so far completed that the 
patient walked with only a slight lameness. 4 Nekton, in a similar 
case of compound luxation, unable to reduce the bone, removed it 
completely, and the patient recovered. 5 

Eobert Smith has called attention to a species of dislocation of the 
internal cuneiform bone not before very accurately described ; but of 
which he has presented two examples. It consists in simultaneous 
dislocation of the metatarsus and internal cuneiform ; that is to say, the 
first metatarsal bone together with the internal cuneiform is dislocated 
upwards and backwards upon the tarsus, carrying with it also the four 
remaining metatarsal bones. In both of the examples seen and re- 

1 Piedagnel, Journ. Univ. et Heb., torn. ii. p. 208. 

2 Walker, The Medical Examiner, 1851, p. 203. 

3 Sir Ast. Cooper, op. eit., p. 383. 

4 Key, Guy's Hosp. Rep., 1836. vol. i. p. 544. 

5 jN'elaton, Malgaigne, op. cit., p. 1076. 



DISLOCATIONS OF THE METATAESAL BONES. 727 

corded by him, the dislocations were ancient, and no account could be 
obtained of the precise manner in which the accidents had been pro- 
duced. The feet were foreshortened to the extent of an inch or more, 
in consequence of the overlapping of the bones, yet the heel in each 
case preserved its natural relations to the tibia, not being proportion- 
ately lengthened as is the case in dislocations of the tibia forwards. 
The plantar surface of the foot was turned inwards, and instead of 
being concave it was convex, both in its antero-posterior and trans- 
verse diameters. A transverse ridge on the top of the foot also indi- 
cated the line of the projecting bones. Both of these cases were veri- 
fied by a careful dissection. 1 

Dupuytren has reported in his Treatise on Injuries of the Bones, a 
similar case, occurring in a woman aet. 30, who was brought immedi- 
ately to Hotel Dieu. She stated that in descending from the bridge 
of St. Michael with a burden of two hundred pounds, she fell in such 
a way that the whole weight of the body was received on the right 
foot, and that at the moment she made an effort to check herself in 
falling, she experienced extremely severe pain in this part, and heard 
a very distinct snap ; she was unable to raise herself from the ground. 
On the following morning Dupuytren reduced the bones with very 
little difficulty by extension, combined with pressure against the dis- 
located ends. The bones went into place with a loud snap, and in 
two or three months she left the hospital with only a little lameness. 2 

Mr. Smith, without intending to question the possibility of a sim- 
ple luxation of the metatarsal bones, of which, indeed, Malgaigne has 
collected a number of well authenticated examples, is inclined to be- 
lieve that, when a luxation of the bones of the metatarsus is the con- 
sequence of a fall from a height, the individual alighting upon the 
anterior part of the foot, it is, in general, that variety which has now 
been described. And this aptness on the part of the cuneiform bone 
to maintain its connection with the first metatarsal bone, he would 
ascribe mainly to the fact that both the peroneus longus and tibialis 
anticus have attachments to each of the bones in question. 



CHAPTEE XXIII. 

DISLOCATIONS OF THE METATARSAL BONES. 

Luxations of one or more of the metatarsal bones, at the points 
of their articulations with the tarsus, have been known to occur in 
almost every direction. They may be occasioned by crushing acci- 
dents, by machinery, or more often perhaps they have been caused 
by a fall backwards or forwards, when the anterior extremity of the 

1 Robert Smith, Treatise on Fractures, &c, Dublin ed., 1854, p. 224 etseq. 

2 Dupuytren, op. cit., p. 326. 



728 DISLOCATIONS OF THE METATAESAL BONES. 

foot was wedged under some solid body and immovably fixed. They 
may be produced also, probably, by simply striking upon the ball of 
the foot in falling from a height. We have noticed, however, that 
Mr. Smith inclines to the opinion that this will, in general, only pro- 
duce the species of dislocation which he has particularly described. 

The symptoms which characterize the dislocation of the whole 
range of metatarsal bones upwards and backwards will, when the dis- 
location is complete, resemble very much those which belong to the 
dislocation described by Smith. The dorsum of the foot will be 
shortened antero-posteriorly, the two arches of the foot will be lost 
upon the plantar surface, or even actually reversed, a ridge will 
traverse the back of the foot and a corresponding depression will 
exist underneath. 

In some cases, however, the dislocation is not complete, the articu- 
lations being only sprung, and then there can exist no foreshortening 
of the foot, and all the other signs will be less striking. 

If only a single bone is luxated the diagnosis is generally very 
easily made out, unless indeed considerable swelling has already oc- 
curred. 

Mr. South says that, in 1835, a case was admitted to St. Thomas's 
Hospital, under Mr. Green's care, of dislocation of the last two meta- 
tarsal bones, occasioned by the falling of a heavy chest upon the inside 
of the foot. Upon the top of the foot was a large swelling below and 
in front of the outer ankle, and behind it a cavity in which two fingers 
could be easily buried, in consequence of the bases of the metatarsal 
bones having been thrown upwards and backwards upon the top of 
the cuboid bone. The reduction was accomplished with much diffi- 
culty by continued extension, and as the bones resumed their place a 
distinct crackling was heard. 1 

Liston reduced a dislocation upwards of the first metatarsal bone ; 
Malgaigne mistook a dislocation of the fourth bone for a fracture, and 
did not attempt the reduction until the seventh day, when, after five 
successive trials, the head entered with a noise into its cavity. In a 
dislocation of the second, third, and fourth metatarsal bones, he also 
failed to detect the true nature of the accident until the tenth day, 
when he proceeded to attempt reduction, but failed. Inflammation, 
suppuration, and delirium followed, and the patient died on the forty- 
first day. Tufnell failed in a similar case, although his patient finally 
recovered with a not very useful limb. Malgaigne failed to reduce 
the bones also in a recent case of luxation of the first four bones, al- 
though he used chloroform, and diligently tried various means. The 
same writer has seen one example of ancient dislocation, which was 
not recognized by the surgeon. Finally, Monteggia reports a case of 
dislocation of the last two metatarsal bones, which was not at the time 
recognized. On the tenth day, swelling commenced, and soon after 
the patient died in convulsions. 2 

These references, drawn chiefly from Malgaigne, sufficiently illus- 

1 South, Note to Chelius's Surg., vol. ii. p. 256. 

2 Malgaigne, op. cit., 1077 et seq. 



DISLOCATIONS OF THE METATARSAL BONES. 729 

trate the difficulty which surgeons have experienced in the reduction 
of these bones, when a portion only is displaced. A difficulty which 
is probably due to the fact that it is almost impossible to make ex- 
tension upon a single metatarsal bone; indeed, it is probable that by 
pressure only upon the displaced head can we expect to accomplish 
much in these accidents, and even this cannot be made to act very 
effectively, owing to the small amount of surface presented against 
which the force can be properly applied. 

If, on the other hand, all the bones are dislocated at once, the 
reduction is generally accomplished with ease by simple extension, 
combined with properly directed pressure. Bouchard and Meynier 
succeeded without difficulty in two cases of backward dislocation ; 
Smyly was equally successful on the sixth day, in a case of disloca- 
tion downwards. Laugier reduced an outward dislocation of all the 
bones by pressure and extension easily ; and Kirk succeeded as well, 
in an example of the opposite character, all the bones being carried 
inwards. 1 

Mr. Sandwith has given us an account of a case which occurred in 
his own person, from the fall of his horse upon his foot. " I was in- 
stantly sensible," says Mr. Sandwith, "of the nature of the injury, 
and as soon as I was upon my feet, the metatarsus was found to be 
drawn upwards, and obliquely outwards upon the tarsus, by the action 
of the flexor muscles. On the removal of the boot, which was cut 
away, these were the appearances : the foot considerably shortened, 
the toes turned a little outwards, and a hard swelling, bigger than an 
egg, upon the tarsus, with tumefaction of the integuments. The pain, 
which was great at first, was kept under by a warm fomentation. 

" The reduction was easily effected by my friends, Messrs. Williams 
and Brereton, and leeches and bread and water poultices prevented 
inflammation. For several nights the foot was violently shaken by 
spasmodic action of the muscles, but the parts preserved their relative 
situation; and, although it was nearly a year before all lameness 
ceased, yet at the end of six weeks I was enabled to lay aside my 
crutches. For the ability to use the foot in so short a time, I was 
indebted to a contrivance which rendered the foot and ankle inflexible. 

" Instead of an elastic sole to the shoe part of the apparatus, one of 
wood was procured, around the heel of which was nailed a piece of 
firm unbending leather ; this reached as high as the calf of the leg ; 
three small straps with buckles held the leg in situ, and a broader one 
across the instep secured the foot. The comfort I experienced from 
this simple apparatus is my reason for describing it so particularly ; it 
has since been found useful in various injuries of the foot and ankle." 2 

In one extraordinary case, however, Dupuytren was not so success- 
ful. Paul Eudes, set. 24, fell, while drunk, into a ditch six feet deep, 
and alighted on the soles of his feet. The accident was followed by 
great swelling, and he did not suspect the nature of the injury, or 

1 Malgaigne, op. cit., p. 1081. 

2 Sandwith, Amer. Journ. Med. Sci., Nov. 1828, p. 216, from Lond. Med. Gaz.,. 
vol. i. 

47 



730 DISLOCATIONS OF THE PHALANGES OF THE TOES. 

present himself at the hospital until three weeks after. Dupuytren 
then ascertained that he had dislocated the metatarsal bones of both 
feet. Several fruitless attempts were made to accomplish the reduc- 
tion, but to no purpose, and in about two weeks he left the hospital. 1 



CHAPTEK XXIY. 

DISLOCATIONS OF THEPHALANGES OF THETOES. 

Dislocations of the toes are less common than those of the flugers, 
yet a considerable number of cases have been recorded "by different 
surgeons. They are occasioned by blows received directly upon the 
ends of the toes, by the weight of the body brought to bear suddenly 
upon their plantar surfaces, as when a horseman springs in his stirrup, 
or by a fall, in consequence of which the rider hangs in his stirrup, 
by leading, &c. 

They may be partial or complete ; and in the latter case, a slight 
overlapping is generally observed. In a great majority of cases the 
direction of the displacement is backwards, or with only a slight lateral 
deviation. Occasionally, several bones are displaced at the same time, 
but usually only one suffers displacement. It is more common here 
to find compound and complicated dislocations than in the case of the 
fingers. 

The position of the toes is not always the same in the same form of 
dislocations. Thus, in the dislocation backwards, the toe is sometimes 
reversed upon the foot to nearly a right angle, and at other times it is 
found lying in the same axis as the metatarsal bone, or the phalanx, 
from which it is luxated. About one year since, I reduced a backward 
dislocation of the first phalanx of the second toe in the person of Lewis 
Britton, aet. 60, who had fallen from a four story window, striking upon 
his feet, and breaking both thighs. I did not discover the dislocation 
of the toe until sixteen hours after the accident. It was then lying 
parallel with the axis of the metatarsal bone, upon which it was 
slightly overlapped. The reduction was effected easily by pulling upon 
the last phalanx with my fingers, while, at the same moment, I pushed 
the head of the bone toward the socket. No swelling followed, nor 
has it troubled 'him at all since his recovery. 

With regard to the treatment, surgeons have experienced the same 
difficulty in certain cases of dislocation of the great toe as we have 
seen experienced in similar dislocations of the thumb. Occasionally, 
indeed, the reduction has been found to be impossible. The same 
doubts have existed also in relation to the causes of this difficulty, and 
in reference to the means by which it was to be overcome. We shall 
therefore refer the reader to the chapter on Dislocations of the First 

1 Dupuytren, op. cit., p. 329. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 731 

Phalanges of the Thumb and Fingers for a more full consideration of 
this matter. 

In case the smaller toes are luxated, the reduction is generally 
effected with ease, by simple extension, or by extension combined with 
pressure ; sometimes, also, the bone will be more easily put in place 
by reversing the phalanx more completely, as we have advised in cer- 
tain cases of dislocation of the fingers. 

If the skin is penetrated, it will often be found necessary either to 
amputate or to practise resection upon the exposed phalanx. 

Sir Astley Cooper relates a case of luxation of "all the smaller 
toes," from the metatarsus, which had not been reduced, and the sub- 
ject of which was, in consequence, so much maimed that he was unable 
to labor. It had been occasioned by a fall, from a considerable height, 
upon the extremities of the toes. A projection existed at the roots of 
ail the smaller toes, the extremity of each metatarsal bone being placed 
under the first phalanx of its corresponding toe. The swelling, which 
immediately followed the receipt of the injury, had concealed its 
nature, and now, several months having elapsed, reduction could not 
be effected. The only relief which could be afforded him, therefore, 
was in wearing a piece of hollow cork at the bottom of the inner part 
of the shoe, to prevent the pressure of the metatarsal bones upon the 
nerves and bloodvessels. 1 



CHAPTEE XXY. 

COMPOUND DISLOCATIONS OF THE LONG BONES. 

Frequency of Compound as compared with Simple Dislocations. — Com- 
pound dislocations, as compared with simple, are of rare occurrence. 
Of ninety-four dislocations reported by JSTorris as having been re- 
ceived into the Pennsylvania Hospital for the ten years ending in 
1840, only two were compound; 2 and of one hundred and sixty-six 
dislocations recorded in my record of personal observation, only 
eight were compound. 3 

Relative Frequency in the Different Joints. — In my own recorded cases, 
four were dislocations of the tibia inwards at the ankle-joint, one was 
a partial (pathological) luxation forwards at the same joint, one was a 
luxation of the astragalus, one a luxation of the head of the humerus 
into the axilla, and one a forward luxation of the radius and ulna at 
the wrist-joint. I have also met with several examples of compound 

1 Sir Ast. Cooper, op. cit., p. 385. 

2 Norris, Amer. Journ. Med. Sci., April, 1841, p. 335. 

3 For the most of these cases, see Transactions of the New York State Med. Soc. 
for 1855 ; article entitled " Report on Dislocations, with especial reference to their 
Results." By F. H. Hamilton. 



732 COMPOUND DISLOCATIONS OF THE LONG BONES. 

dislocations of the fingers. Both of the cases reported by Norris were 
dislocations of the thumb. 

Sir Astley Cooper, speaking upon this point, says that the elbow, 
wrist, ankle, and finger-joints are most subject to these accidents; and 
that he has seen but two in the shoulder-joint, and one in the knee- 
joint. He had never seen a compound dislocation at the hip-joint, and 
he believed that it was "scarcely ever" so dislocated. Mr. Bransby 
Cooper has, however, reported in detail a very interesting case of this 
accident, communicated to him by Dr. Walker, of Charlestown, Mass., 
in which reduction was accomplished by manipulation alone, by Dr. 
Ingalls, on the second day. The patient died at the end of about three 
weeks. 1 So far as I know, this is the only case upon record. Mal- 
gaigne says that a compound dislocation at the hip-joint has probably 
never occurred. 

Among the cases of compound dislocation recorded by Sir Astley 
and Bransby Cooper, most of which were communicated to these gen- 
tlemen by other surgeons, 45 were dislocations of the ankle, 10 of the 
astragalus, 4 of the ulna at the wrist-joint, 4 of the thumb, 2 of the 
knee, 1 of the shoulder, 1 of the elbow, 1 of the radius and ulna at 
the wrist, 1 of the scaphoid bone, and 1 of the metatarsal bone of the 
great toe. Other writers have occasionally described compound dis- 
locations of the clavicle, but I know of no record of a compound dis- 
location of the lower jaw. 

Prognosis, as determined by the Mode of Treatment adopted by most of 
the Ancient and many of the Modern Surgeons. — By most of the early 
writers these accidents, whenever they occurred in the larger joints, 
were regarded as nearly beyond the reach of art. Says Hippocrates : 
"In cases of complete dislocation at the ankle-joint, complicated with 
an external wound, whether the displacement be inwards or outwards, 
you are not to reduce the parts, but let any other physician reduce 
them if he choose. For this you should know for certain, that the 
patient will die if the parts are allowed to remain reduced, and that 
he will not survive more than a few days, for few of them pass the 
seventh day, being cut off by convulsions, and sometimes the leg and 
foot are seized with gangrene." Hippocrates adds: "But if not re- 
duced, nor any attempt at first made to reduce them, most of such 
cases recover." 2 

The same remarks are applied by Hippocrates to compound dislo- 
cations of the head of the tibia, of the lower end of the femur, of the 
wrist, elbow, and shoulder-joints ; death occurring in all cases, as he 
believes, more or less speedily whenever the bones are reduced and 
retained in place a sufficient length of time, and " were it not that the 
physician would be exposed to censure," he would not reduce even 
the bones of the fingers, since it must be expected, he thinks, that 
their articular extremities will exfoliate even when the reduction is 
most successful. 

1 A. Cooper, on Dislocations, &.c, by B. Cooper, p. 59. 

2 Works of Hippocrates, Sydenham ed., London, vol. ii. p. 634. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 733 

I shall presently show, however, that even Hippocrates advised and 
probably practised resection in certain cases of these accidents. 

Both "Celsus and Galen adopt almost without qualification the line 
of practice laid down by Hippocrates, and affirm equally the danger 
and almost certain death, consequent upon the reduction of compound 
dislocations in large joints. 1 Celsus recommends resection in some 
cases. 

Paulus iEgineta, however, and after him Albucasis, Haly Abbas, 
and Ehazes, do not regard the rules established by Hippocrates, in 
relation to the non-reduction of the bones, as so imperative, nor the 
results of the opposite practice as so uniformly fatal. 

" Hippocrates remarks," says Paulus iEgineta, " in the case of dis- 
locations with a wound, the utmost discretion is required. For these, 
if reduced, occasion the most imminent danger, and sometimes death, 
the surrounding nerves and muscles being inflamed by the extension, 
so that strong pains, spasms, and acute fevers are produced, more par- 
ticularly in the case of the elbows, knees, and joints above, for the 
nearer they are to the vital parts the greater is the danger they induce. 
"Wherefore, Hippocrates, by all means, forbids us to apply reduction 
and strong bandaging to them, and directs us to use only anti-inflam- 
matory and soothing applications to them at the commencement, for 
that by this treatment life may sometimes be preserved. But what 
he recommends for the fingers alone, we would attempt to do for all 
the other joints; at first, and while the parts remain free from inflam- 
mation, we would reduce the dislocated joint by moderate extension, 
and if we succeed in our object, we may persist in using the anti-in- 
flammatory treatment only. But if inflammation, spasm, or any of 
the afore-mentioned symptoms come on, we must dislocate it again if 
it can be done without violence. If, however, we are apprehensive of 
this danger (for perhaps if inflammation should come on it will not 
yield), it will be better to defer the reduction of the greater joints at 
the commencement; and when the inflammation subsides, which 
happens about the seventh or ninth day, then, having foretold the 
danger from reduction, and explained how, if not reduced, they will 
be mutilated for life, we may try to make the attempt without violence, 
using also the lever to facilitate the process." 2 

In the following quotations from three of the most celebrated 
writers of the last two centuries, we find but little, if any evidence 
that the opinions of the fathers upon this subject were not still held 
in general respect: "If the joint be dislocated, so that it is either 
uncovered, or a little thrust forth without the skin, the accident is 
mortal, and of more danger to be reduced than if it be not reduced. 
For if it be not reduced, inflammation will come upon it, convulsion, 
and sometimes death. 2. There will be a filthiness of the part itself. 
3. An incurable ulcer, and if perhaps it be brought to cicatrize at all, 
it will easily be dissolved by reason of the softness of it ; but if it 

1 Paulus ^gineta, Syd. ed., vol. ii. p. 510. 

2 Ibid., p. 509. 



734 COMPOUND DISLOCATIONS OF THE LONG- BOXES. 

be reduced, it brings extreme danger of convulsion, gangrene, and 
death." 1 

" Si vero in magnis articulis tarn valida fuit facta luxatio, ut liga- 
mentis ruptis os articuli multum sit protrusum per integumenta, haec 
pars ossis vasis privata moritur, citius autem si reponatur, quam si 
non reponitur; quare sola amputatio restat ad conservationem vitse." 2 

Heister, who makes no allusion to this subject in the first edition 
of his great work, published at Amsterdam in 1739, adds the following 
remarks in his last edition, translated and published in London in 
1768 : "Dislocations attended with a wound, especially of the shoulder 
or thigh-bone, are of very bad consequence, and often endanger the 
life of the patient; in Celsus's opinion (Book YIII. Chap. XXV.), 
whether the bones be replaced or not, there is generally great danger ; 
and so much the more the nearer the wound is to the joint. Hippo- 
crates has declared that no bones can be reduced with security, beside 
those of the hands and feet. ( Vectiar. 19, 5). See more on this subject 
in that passage of Celsus just now quoted, though I by no means re- 
commend the following him implicitly." 3 

Such were the extreme views as to the fatality of these accidents, 
and of the feebleness of our resources entertained by the ancient, and 
even by the more modern writers almost down to our own day ; with 
only rare exceptions these limbs were condemned either to great and 
inevitable deformity, or to amputation. Nor, if we speak only of 
their fatality, have surgeons ceased to regard these accidents as among 
the most grave with which they have to deal. 

Pathology and Appreciation of the Sources of Danger as compared 
especially with Compound Fractures. — The danger, according to Sir 
Astley Cooper, consists in the rapid inflammation of the synovial 
membranes, which is speedily followed by suppuration and ulceration 
whereby the ends of the bones become exposed; and for the repair of 
which lesions, great general as well as local efforts are required, and 
a high degree of constitutional irritation results. In addition to which 
circumstances, "the violence inflicted on the neighboring parts, the 
injury of the muscles and tendons, and the laceration of bloodvessels, 
necessarily lead to more important and dangerous consequences than 
those which follow simple dislocations." 

The sources of danger enumerated by Sir Astley Cooper have been 
regarded as sufficient to account for their extraordinary fatality by 
the majority of those modern surgical writers who have alluded to 
the subject ; but I must confess that to me they do not appear so. In 
compound fractures the mortality is far less ; yet one might naturally 
suppose, that when the sharp and irregular fragments are pressing 
into the flesh, among nerves and bloodvessels, the irritation and in- 
flammation would be equal, if not more than equal to the irritation 
and consequent inflammation produced by exposing a joint surface to 

1 " Cliirurgeon's Storehouse." By Johannes Scultetus, of dime, in Suevia. London 
ed., 1674, p. 31. 

2 Johannes de Corter. Chirurgia repurgata. Lusduni Batavorem, 1742. t. 86. 

3 General System of Surgery, by Dr. Laurence Heister. 8th ed. London, 1768. 
Vol. i. p. 164. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 735 

the air; indeed, modern experience has sufficiently shown that these 
surfaces are much more tolerant of atmospheric exposure, and of the 
action of many other irritants, than surgeons formerly supposed. A 
clean incision into a large joint, which exposes the synovial mem- 
branes to the air, and which permits the products of inflammation to 
escape freely, is attended with much less danger than a small punc- 
ture which does not at all permit the air to enter, nor the increased 
synovia and the pus to escape. Very grave results sometimes follow 
from large wounds into large joints, but under judicious treatment 
such results are the exception and not the rule. 1 But Sir Astley evi- 
dently attributes more of the bad consequences to the exhausting 
effects of the efforts at repair, than to the immediate inflammation re- 
sulting from the exposure of the joint. It is pretty certain, however, 
that a majority of these patients die at a period too early to render 
this cause in any considerable degree operative. 

As to the bruising of the "muscles and tendons, and laceration of 
bloodvessels," it cannot be denied that it must usually be greater than 
in " simple dislocations ;" and I will not say that it is not in a given 
number of instances greater than in the same number of instances of 
compound fractures. The tissues have often been thrust rudely through 
by a large and smooth bone, and the tendons have been stretched vio- 
lently or torn completely asunder ; while occasionally large arteries, 
which are prone to hug the bones about the joints, are lacerated and 
left to bleed. That the importance of these complications, however, 
may not be over-estimated, we must state that Sir Astley Cooper him- 
self has remarked how seldom, in compound dislocations of the ankle- 
joint, the large arteries are injured; that a tearing of the ligaments 
and of the tendons is almost as likely to occur in simple dislocations 
as in compound; and, indeed, that in neither case are the tendons 
usually ruptured, but only thrust aside. Moreover, the skin is often 
made to give way not so much from the pressure of the round head 
within, as from the equal pressure of some sharp angular body from 
without. In all these respects, there are many examples of compound 
fractures which possess not a whit of advantage ; in which cases, never- 
theless, the surgeon feels very little doubt as to the ultimate cure. 

In short, the causes which, according to Sir Astley Cooper, deter- 
mine the extraordinary fatality of these accidents, do not sufficiently 
differ from those which operate in compound fractures to occasion so 
great a difference in results, and the fatality of compound dislocations 
remains unexplained ; or if surgical writers have here and there in- 
timated the true cause, they have failed to give it its proper place and 
value. 

I think the cause of the greater fatality of compound dislocations 
over compound fractures is to be found in the simple fact that dislo- 
cations are generally reduced, and by splints or other apparatus suc- 
cessfully maintained in place, while compound fractures, as my 

1 Upon this point see the very ahle article entitled " Amputations and Compound 
Fractures," by John 0. Stone, in the New York Journal of Medicine, vol. iii. of 2d 
series, p. 316, Nov. 1849. 



736 COMPOUND DISLOCATIONS OF THE LOXG- BOXES. 

statistical report of cases has proven, are not generally reduced com- 
pletely, nor can they by any means yet devised, except a few cases, 
be maintained in place if reduced. Broken limbs, whether simple or 
compound in their character, will in a great majority of cases shorten 
upon themselves in spite of the most assiduous and skilful attempts 
to prevent it. 1 

In adults most bones break obliquely, and cannot be made to sup- 
port each other, and even in transverse fractures the broken ends are 
generally small compared with the articular ends of the same bones, 
and afford a very uncertain and inadequate support for themselves ; 
not to speak of the difficulty of once bringing their ends into exact 
apposition where the muscles are powerful, or where they lie imbed- 
ded in a large mass of flesh so that they cannot be felt. While, on 
the other hand, dislocated bones, whether simple or compound, are 
capable when restored to place of supporting themselves; or with 
only slight assistance, their reduction may be maintained ; it is also 
ordinarily a work of no great difficulty to reduce them. 

Herein, then, consists the most important difference between these 
two classes of accidents, which are in other respects so similar. In 
the one, the very nature of the injury prevents the complete reduc- 
tion, and the consequent violent strain of the muscles, tendons, and 
other soft tissues ; while in the other, the nature of the accident leaves 
it in the power of the surgeon to reduce the bones, and modern sur- 
gery has in a great measure sanctioned the practice of maintaining 
them in place, in defiance of the efforts of the muscles, and sometimes, 
no doubt, at the imminent hazard of the life of the patient. 

Is it not fair to presume that tissues which have been stretched and 
lacerated, require rest in order that they may recover from the effects 
of their injuries? And if the soft parts are really more injured in 
dislocations than in fractures, does not the indication for rest become, 
for this very reason, more imperative ? 

General Inferences. — We have come, then, to regard the shortening 
of limbs after fractures, within certain limits and in certain cases, as 
a conservative circumstance rather than as a circumstance which the 
surgeon should in all cases seek to prevent. 

There is abundant evidence that the ancients had some knowledge 
of the value of rest to the muscles, tendons, &a, in the prevention of 
inflammation after compound dislocations, since they constantly urge 
the greater danger of reducing these dislocations, than of leaving 
them unreduced ; and they do not hesitate to recommend, that in case 
violent inflammation supervenes upon the reduction, the bone shall 
immediately be again dislocated. Galen speaks very explicitly on 
this subject, and says that " the danger in reduction consists partly in 
the additional violence inflicted on the muscles, and partly in their 
being then put into a stretched state, whereby spasms or convulsions 
are brought on, and gangrene as the result of the intense inflamma- 
tion which ensues ;" and Paulus ^Egineta remarks : " For these, if re- 

1 " Report on Deformities after Fractures." Trans. Am. Med. Assoc, vol. viii. ix. 
and x. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 737 

duced, occasion the most imminent danger, and sometimes death ; the 
surrounding nerves and muscles being inflamed by the extension," &c. 

I have already quoted from Sir Astley Cooper the causes or rea- 
sons which he has assigned for the fatality of compound dislocations ; 
and the same reasons have generally been assigned by those who have 
written since his day ; but he has elsewhere, when speaking of ex- 
section, given place to the very idea for which we claim so much pro- 
minence, the danger arising from a stretching of the muscles. Mr. 
Liston, also, and Mr. Miller, when speaking especially of dislocations 
of the tibia at the ankle-joint, refer to the same source of danger. 

Treatment. — Let us see now the alternatives which surgery presents 
for the treatment of these intractable accidents. 

1. Eeduction of the bone. 

2. Non reduction. 

3. Amputation. 

4. Tenotomy. 

5. Eesection and reduction. 

The questions for us to consider are, first, by which of these several 
methods is the life of the patient rendered most secure ? and second, 
where, of two or more methods, all are equally safe, by which will he 
suffer the least maiming or mutilation ? 

By Reduction. — We have seen already how the old surgeons re- 
garded the practice of reducing compound dislocations of the larger 
joints. It is not difficult, however, to find in the records of surgery 
numerous examples of successful terminations under this practice. 

Dr. White, of Hudson, 1ST. Y. ; has reported a case of this kind in 
which the dislocation was at the ankle-joint. 1 Pott says he has seen 
this practice occasionally succeed, 2 and Mr. Scott communicated to 
the Lancet in March, 1837, a case of compound dislocation of the 
humerus successfully treated by reduction. Sir Astley Cooper also 
records several cases of compound dislocations at the lower end of the 
tibia and fibula, successfully treated by reduction. 

A careful examination, however, of those cases reported by Sir 
Astley as having been reduced without resection, and which resulted 
in cures, does not, in my opinion, leave much substantial evidence in 
favor of the practice ; or perhaps we ought rather to say that it leaves 
only a qualified evidence of its propriety in certain cases. He has 
mentioned about sixteen of these examples, comprising dislocations of 
the lower end of the tibia, or of the tibia and fibula, outwards, also 
inwards and forwards, all of which, save one quoted from Mr. Liston, 
have been reported to him by other surgeons, and not one of which 
had he ever seen himself. Many of the cases are reported very loosely, 
evidently in reply to circular letters, and from memory, without re- 
corded notes, and by unknown, and in some sense irresponsible sur- 
geons. It is not always said whether the wounds in the soft parts 
were made by the protrusion of the bones, or by some external 
violence ; yet this is certainly a very material point in determining 

1 White, Amer. Journ. Med. Sci., Nov. 1828, p. 109. 

2 Pott, Chirurg. Works, vol. ii. p. 243. 



738 COMPOUND DISLOCATIONS OF THE LONG BONES. 

whether reduction is to be followed by inflammation or not. The 
results, sometimes only attained after exposure to great hazards, are, 
after all, often sufficiently unfavorable. 

It will be noticed, also, that in Cases 152 and 153, the astragalus 
was comminuted and removed, either at first or at a later day ; and 
in Cases 154, 155, 156, and 160, the tibia, and also probably the 
fibula, were broken, and it does not appear but that in consequence of 
this complication the limb became shortened, and the muscles were 
thus put at rest, very much as if the bones had been retracted ; and 
in one of the cases enumerated under 161, the lower end of the tibia 
spontaneously exfoliated. That a comminution, or that any fracture 
of the astragalus, or of the tibia and fibula, should be regarded in these 
cases as rendering the accident less grave, can only be comprehended 
by a full appreciation of the value of relaxation of the muscles. 

The few cases which remain after this exclusion do indeed illustrate 
how nature and skill may triumph over great difficulties, but nothing 
more. 

It is possible, also, that some of these examples of recovery after 
reduction may admit of an explanation entirely consistent with our 
own views of the true source of the danger in these accidents, if indeed 
they do not tend actually to confirm our doctrines. I have myself 
seen one example of complete recovery after the reduction of a com- 
pound dislocation at the ankle-joint, although resection was not prac- 
tised ; but in this case, all the tissues, or nearly all which suffered any 
injury, were completely torn asunder, and therefore wholly removed 
from the danger of which we have spoken. The example to which 
we allude is the following: On the 30th of Oct. 1858, John Bourquard, 
8Bt. 30, was caught in the tow-line of a canal boat, causing a compound 
dislocation of the right ankle-joint. I found the foot, immediately 
after the accident, thrown completely back against the lower part of 
the leg, the integuments in front of the joint, as well as all of the ten- 
dons and ligaments on this side, being completely torn asunder, while 
the tendo-Achillis, and the tendons behind both of the malleoli, with 
the corresponding integuments, were uninjured. This immunity of 
the tissues behind the malleoli was due to the direction in which the 
foot was drawn, namely, directly backwards. Everything which had 
suffered a strain being thoroughly severed, I did not hesitate to attempt 
to save the limb without resection. The reduction was accomplished 
very easily. The leg and foot were placed in a box filled with bran, 
and cool water dressings were applied to the portion which was ex- 
posed. On the 22d of November the limb was removed from the 
bran to a pillow, the union being sufficient not to demand so much 
lateral support. About the first of March he left the hospital, the 
wound having closed, but the ankle remaining swollen and stiff. 

I have also during the last year seen two cases in which the foot 
has been nearly severed from the leg through the ankle-joint, by means 
of a "reaper." In each case the patient was standing with his back 
to the machine, and one of the blades cut horizontally from side to 
side, severing everything except about three inches of integument in 
front, and the extensor tendons of the toes. In the first instance, having 



COMPOUND DISLOCATIONS OF THE LONG BONES. 739 

seen the patient, a gentleman nearly sixty years of age, within three 
or four hours of the time of the receipt of the injury, I found him ex- 
ceedingly exhausted by the hemorrhage. Both malleoli were cut off 
smoothly, the knife having severed the limb so exactly through the 
joint, as to have touched the cartilage at but one or two points. Having 
secured the bloodvessels, I replaced the foot, and after a few days of 
attendance I left him in the charge of an excellent young surgeon, 
Dr. Eobertson, of Lancaster, N. Y., to whose diligence and skill the 
patient is no doubt mainly indebted for his recovery. After the lapse 
of nearly one year he is able, by the assistance of a shoe furnished with 
lateral supports, to walk very well. In the second case, which was 
only brought to my notice some months after the accident occurred, 
in consequence of a troublesome fistula near the ankle-joint, the re- 
covery had been complete except that a small fragment of one of the 
malleoli was necrosed and required removal. 

Dr. Eli Hurd, of Niagara Co., 1ST. Y., was equally fortunate in a case 
of compound dislocation of the shoulder-joint. This was in the person 
of Gr. T., set. 30, who was caught in the gearing of a threshing machine 
on the ISth of Feb. 1852, which having drawn him in with great force 
dislocated the head of the left humerus downwards through the integu- 
ments into the axilla. Reduction was accomplished according to the 
method recommended by Nathan Smith, by pulling from each wrist 
at right angles with the body, while the operator himself seized the 
naked head of the humerus with his left hand, his right resting upon 
the top of the shoulder, and pushed it into place. The time occupied 
in- the reduction was about thirty seconds. The forearm was then 
suspended in a sling, and the venous hemorrhage, occasioned by a 
rupture of the subclavian vein, was arrested by compression. The 
tegumentary wound, between three and four inches in length, was 
subsequently closed by sutures, and cool water-dressings were applied. 
On the fourth day the wound had united by first intention, and the 
man was walking about his room. In less than a month he was dis- 
missed cured, and in the following harvest he was able to cut his own 
hay and grain, and to use his arm as before the accident. 1 

Miller and Hoffman reduced successfully a compound dislocation 
of the knee, 2 and Gralli has communicated a similar case to Malgaigne. 3 

Whether either of the last three mentioned examples admit of the 
same explanation as the preceding three, I am unable to say, but 
whether they do or do not, they are too exceptional in their character 
to prejudice the argument materially which we shall hereafter make 
in favor of resection. 

Non- Reduction. — On the other hand, it will be very difficult to find 
an equal number of cases of compound dislocations, unreduced, which 
have terminated favorably. The fact is, no doubt, that at the present 
day very few surgeons would feel themselves justified in leaving a 
bone out of place unless they proceeded to amputate. In the Trans* 

1 Hurd, Buffalo Med. Journ., vol. ix. p. 119. 

2 Miller and Hoffman, London Med. Repos., vol. xxiv. p. 346. 

3 Galli, Malgaigne, op. cit., t. ii. p. 958. 



710 COMPOUND DISLOCATIONS OF THE LONG BONES. 

actions of the New York State Medical Society for 1855, I have re- 
ported (Case 16 of Tibia and Fibula, p. 87) a compound dislocation 
at the ankle-joint, which, being unreduced, terminated fatally on the 
twenty-eighth day. This is the only example of a compound dislo- 
cation of a long bone, left unreduced, which has fallen under my 
observation; excepting, of course, those cases in which amputation 
was immediately practised. 

The united testimony, however, of the old surgeons, who generally 
neither amputated nor adopted the method of resection, but who re- 
commended and practised non-reduction, is, that it is much more safe 
to leave these bones unreduced, than to reduce them without resec- 
tion; and I see no reason to doubt the correctness of their opinions 
in this matter. But whether it would be more safe to leave such 
limbs unreduced, or having practised resection to restore them, is 
another question, in which the advantage and comparative safety of 
the latter practice is too obvious to require explanation or defence. 

Amputation. — Says Pott: "When this accident (dislocation of the 
ankle) is accompanied, as it sometimes is, with a wound of the integu- 
ments of the inner ankle, and that made by the protrusion of the bone, 
it not unfrequently ends in a fatal gangrene, unless prevented by 
timely amputation, though I have several times seen it do very well 
without." And Sir Astley Cooper, speaking of compound disloca- 
tions of the ankle-joint, remarks: "Thirty years ago it was the prac- 
tice to amputate limbs for this accident, and the operation was then 
thought absolutely necessary for the preservation of life, by some of 
our best surgeons." ISTor is it difficult to see by what reasoning sur- 
geons of "thirty years ago" had fallen back upon this desperate remedy. 
Both reduction and non-reduction having proven eminently hazardous, 
in the absence of perhaps both knowledge and experience in resec- 
tion, they finally adopted the alternative of amputation, as that which 
after all must give to the patient the best chance for life; and were 
no other alternatives to be presented, this would be our choice in a 
large proportion of cases. 

It must not be understood, however, that amputation is an expedient 
wholly free from danger; or, indeed, that the chances of the patient 
are in the average very greatly increased by this practice. Of thirteen 
amputations made for compound dislocations at the ankle-joint, in the 
Royal Infirmary at Edinburgh, only two resulted in the recovery of 
the patients. 1 Alluding to which, Mr. Fergusson remarks: "An 
amount of mortality which may well incline the surgeon to act upon 
the doctrine inculcated by Sir Astley Cooper," to (attempt to save 
the limb by reduction). But Mr. Fergusson has added a sentiment 
which accords very closely with my own experience and opinions. 
"I fear, however, that in the attempts which have been made to save 
the foot (by reduction) the results in all the cases have not met with 
the same publicity; that the instances where amputation has been 
afterwards necessary, or where death has been the consequence, have 
not always been recorded; and, from what I have myself seen, I would 

i Ediub. Med. Monthly, Aug. 1844. 



COMPOUND -DISLOCATIONS OF THE LONG BONES. 741 

caution the inexperienced practitioner from being over-sanguine in 
anticipating a happy result in every example." 

By Tenotomy. — As a means of overcoming the resistance of the 
muscles, and for the purpose especially of facilitating the reduction, 
tenotomy has been proposed. First by Dieffenbach in cases of ancient 
unreduced luxations; but fm. Hey, Jr., was the first to make a prac- 
tical application of this suggestion in a case of compound dislocation. 
After cutting the tendo-Achillis, the ankle being dislocated, the re- 
duction was easily effected, but a strong tendency to displacement 
backwards remained, and he was obliged afterwards to cut the ten- 
dons of the tibialis posticus and flexor longus digitorum. 1 

This method, based in some degree upon a very correct notion of 
the principal sources of difficulty, I regard as totally impracticable, 
at least to any useful or adequate extent?. In order to be efficient, all 
the tendons passing the articulations must be cut, or nearly all of 
them; and I doubt whether the judgment of any discreet surgeon 
will ever sanction such an extreme, I might almost say, such an ab- 
surd measure. Nor do I think that in the point of view in which we 
are now considering this subject, having reference only to the ques- 
tion of danger, if the cutting of the tendons was sufficiently extensive 
to have any real effect in facilitating the reduction, the practice would 
be found to have any advantage over other methods known to be 
eminently dangerous. 

By Resection. — Finally, resection presents itself for our considera- 
tion as the only remaining surgical expedient. 

We have seen that most of the early writers understood the effects 
of a constant strain upon the muscles in increasing the danger of 
spasms, inflammation, and death ; but in general they have suggested 
no remedy but non-reduction or amputation. Hippocrates, however, 
uses the following language, after speaking of resection of protruding 
bones in accidental amputations, or in fractures of the fingers: "Com- 
plete resections of bones at the joints, whether the foot, the hand, the 
leg, the ankle, the forearm, the wrist, for the most part, are not at- 
tended with danger, unless one be cut off at once by deliquium animi, 
or if continued fever supervene on the fourth day." To which pas- 
sage the translator adds the following note : " This paragraph on re- 
section of the bones in compound dislocations and fractures contains 
almost all the information on the subject which is to be found in the 
works of ancient medicine." Celsus notices the practice of resection 
in compound dislocations very briefly, as follows : " Si nudum os emi- 
net, impedimentum semper futurum est ; ideo quod excedit, abscin- 
dendum est." 

Mr. Hey, of Leeds, was the first of modern surgeons who called 
especial attention to the value of resection in compound dislocations. 

Subsequently, Mr. Parks, of Liverpool, in an " Account of a new 
method of treating Diseases of the Joints of the Knee and Elbow," 
advocates the practice of resection in certain cases of diseases of these 

1 Hey, Trans, of Provinc. Med. and Surg. Assoc, vol. xii. p. 171, 1S44. 



742 COMPOUND DISLOCATIONS OF THE LONG BONES. 

joints, "but especially in " affections of the joints produced by external 
violence." 

Mr. Leveille, in France also, following, as he affirms, the guidance 
of Hippocrates, has advocated a similar practice. 

Velpeau, Syme, Fergusson, Erichsen, Miller, Liston, Chelius, Lizars, 
Gibson, ISTorris, under certain circumstances, and especially where the 
bones cannot otherwise be reduced, and where the dislocations occur 
in certain joints, and especially the elbow and ankle-joints, recommend 
resection. To which names we may add that of Sir Astley Cooper, 
who has considered the subject, as applied to the ankle-joint, quite at 
length, and who says : " I have known no case of death when the ex- 
tremities of the bone" (tibia, at the ankle) "have been sawed offj 
although I shall have occasion to mention some cases which termi- 
nated fatally when this was not done." 

Why resection should diminish the danger to life, by placing at 
rest the injured muscles, has been already sufficiently considered ; but 
it seems not improbable that, if synovial membranes are actually 
more susceptible of violent and dangerous inflammations than the 
other tissues about the joints, then wo aid this source of danger be 
removed just in proportion as the synovial membranes themselves are 
removed. Such, indeed, was the argument used by Sir Astley ; and 
Mr. South, in a note to Chelius, when referring to this fact, has made 
the following statement : — 

"In compound dislocations of the ankle-joint, with protrusion of 
the shin-bone through the wound, most English surgeons saw off the 
joint end, not merely to render reduction more easy, but also, accord- 
ing to Sir Astley Cooper's opinions, to lessen the suppurative process, 
by diminishing the synovial surface. This mode of practice is cer- 
tainly not commonly followed in reference to other joints, and the 
younger Cline was always opposed to its being resorted to in dislo- 
cated ankle." 

The following case, having occurred under my own eye, will serve 
to illustrate the value of the principle which I have been endeavoring 
to establish: — 

Samuel Adamson, of Buffalo, set. 24, was caught by the cable of a 
vessel, June 17, 1855, dislocating the left tibia at its lower end in- 
wards, and breaking the fibula two inches above the ankle. I was 
immediately called, and found the tibia protruding through the skin 
about three inches. The periosteum was torn up, and the cartilagi- 
nous surface of the end of the bone was roughened. His thigh was 
also severely bruised and lacerated, but the bone was not broken. 

Dr. Boardman assisting me, we attempted to reduce the bones, but 
with our hands we found it impossible to do so. I proceeded imme- 
diately to remove about one inch and a half of the lower end of the 
tibia with the saw. The remaining portion was then brought easily 
into place, and the wound dressed with sutures, adhesive straps, band- 
ages, and light splints. On the same day he became an inmate of the 
marine wards at the Hospital of the Sisters of Charity, and was placed 
under the care of Dr. Wilcox, through whose politeness I was per- 
mitted to see him frequently. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 743 

The wound in the leg healed kindly, with only a slight amount 
of inflammation and suppuration. Yiolent inflammation, however, 
occurred in the thigh, followed by extensive suppuration and slough- 
ing. This, in fact, proved to be by far the most serious injury, and 
that which most endangered his life and delayed his recovery. 

After about two months, the ankle was in such a condition as to 
require little or no further attention. The fragments of the fibula had 
shortened upon each other and were united, so that the tibia rested 
upon the astragalus. It was nearly two months, however, before he 
began to walk, owing to the condition of his thigh. 

Aug. 24, 1856, fourteen months after the accident, Adamson called 
at my office. He was then employed again as a sailor on board the 
schooner Sebastopol, and performed all the duties of an ordinary deck 
hand. His leg is shortened one inch and a quarter ; from which, it 
seems, that there has been some deposit upon the end of the bone, 
which has compensated for one-quarter of an inch of that which I 
removed. The ankle is perfect in its form, being neither turned to the 
right nor to the left, and he treads square and firm upon the sole of 
his foot. There is considerable freedom of motion, especially in flexion 
and extension. Occasionally it becomes a little swollen and painful. 

In a case of compound dislocation of the upper end of the humerus, 
occurring also under my own observation, and recorded in the Trans- 
actions of the New York State Medical Society for 1855 (p. 27, Case 14), 
in which reduction was followed by death, I have now much reason 
to believe that if I had practised resection before the reduction, my 
patient's chances for recovery would have been greatly increased ; 
perhaps also the case of compound dislocation at the wrist-joint re- 
corded in the same vol. (p. 68), in which, having reduced the bones, 
I was subsequently compelled to amputate, may equally illustrate the 
hazard to which the practice of reduction without resection must often 
expose the patient. 

The same remarks I will venture to apply to the case of compound 
dislocation of the hip, of which I have already spoken as having oc- 
curred in the practice of Dr. Walker, of Charlestown, Mass. Had the 
head of the femur been resected before its reduction, I cannot doubt 
but that the unfortunate man's chance for recovery would have been 
very greatly improved. 

Thus, if we consider the question of the life of the patient only, the 
argument and the testimony seem to favor resection in a great ma- 
jority of cases of compound dislocations occurring in large joints, and 
in a considerable number of cases of similar accidents in the smaller 
joints. It is certainly more safe than non-reduction or reduction 
without resection, and it is probably quite as safe as amputation or 
tenotomy. 

But there is another question, which is, in our estimation, secondary 
to the one now considered, but which is often in the estimation of the 
patient himself of the first importance, namely, by which method will 
he suffer the least maiming or mutilation? 

This question I do not find it difficult to answer. Certainly it is 
not by non-reduction or by amputation; and, putting tenotomy aside, 



74A COMPOUND DISLOCATIONS OF THE LONG BONES. 

it is now a question only between reduction without resection, and 
reduction with resection. These two methods, one of which experi- 
ence has shown to be fraught with danger, and the other of which 
experience has shown to be relatively safe, are now to be compared in 
a point of view in which their antagonisms are perhaps less conspicu- 
ous, yet sufficiently marked. 

First. In either case the inflammation consequent upon the injury 
may be violent, and the recovery slow and tedious. The same argu- 
ments, however, which we have applied to the question of the com- 
parative danger of the two modes, must apply with nearly equal force 
to this question of maiming; since the amount of maiming must often 
be governed by the intensity and duration of the inflammation, and 
upon this point the testimony has been shown to be in favor of re- 
section. 

It will be observed that not only is the danger of maiming rendered 
more considerable by reduction without resection, because the inflam- 
mation is so much more likely to extend to the tendons and muscles, 
causing them to adhere to each other, and to become subsequently 
atrophied, a condition from which they often never completely recover, 
but also because the ligaments and capsules of the joints, with the 
synovial surfaces, are in consequence encroached upon, and the free- 
dom of motion is ever afterwards greatly restricted, if not completely 
lost. This marked impairment of the functions of the joint does not 
always happen, but it cannot be denied that it does generally. Indeed 
it is by no means uncommon for these accidents to be followed, after 
ulcerations of the cartilage, by copious bony deposits in and around 
the joints. 

How is it, on the other hand, with these joints after resection ? I 
have thus far heard of no cases in which complete anchylosis resulted; 
but in all considerable freedom of motion has returned, and in some 
the restoration in this respect has been nearly or quite as complete as 
before the accident. 

Says Dr. Kerr, of Northampton: "Several cases of compound 
dislocation of the ankle have fallen under my care, and it has been 
uniformly my practice to take off the lower extremity of the tibia, and 
to lay the limb in a state of semiflexion upon splints ; by this means 
a great degree of painful extension, and the consequent high degree 
of inflammation, are avoided. The splints I used are excavated wood, 
and much wider than those in common use, with thick movable pads 
stuffed with wool. I keep the parts constantly wetted with a solution of 
liquor ammonias acetatis, without removing the bandage. In my very 
early life, upwards of sixty years ago, I saw many attempts to reduce 
compound dislocations without removing any part of the tibia ; but, 
to the best of my recollection, they all ended unfavorably, or, at least, 
in amputation. By the method which I have pursued, as above men- 
tioned, I have generally succeeded in saving the foot, and in preserving 
a tolerable articulation." 

Sir Astley Cooper has made a valuable experiment to determine 
the condition of the new joint under these circumstances ; and the vast 
number of cases in which resection has now been practised in cases of 



COMPOUND DISLOCATIONS OF THE LONG BONES. 745 

caries of the articulating surfaces, and their results, add still more 
substantial proofs as to the usefulness of the joints after such opera- 
tions. 

" I made an incision upon the lower extremity of the tibia, at the 
inner ankle of a dog, and cutting the inner portion of the ligament of 
the ankle-joint, I produced a compound dislocation of the bone in- 
wards. I then sawed off the whole cartilaginous extremity of the 
tibia, returned the bone upon the astragalus, closed the integuments 
by suture, and bandaged the limb to preserve the bone in this situa- 
tion. Considerable inflammation and suppuration followed; and in a 
week the bandage was removed. When the wound had been for 
several weeks perfectly healed, I dissected the limb. The ligament 
of the joint was still defective at the part at which it had been cut. 
From the sawn surface of the tibia there grew a ligamento-carti- 
laginous substance, which proceeded to the surface of the cartilage of 
the astragalus to which it adhered. The cartilage of the astragalus 
appeared to be absorbed only in one small part ; there was no cavity 
between the end of the tibia and the cartilaginous surface of the astra- 
galus. A free motion existed between the tibia and astragalus which 
was permitted by the length and flexibility of the ligamentous sub- 
stance above described, so as to give the advantage of a joint where 
no synovial articulation or cavity was to be found. This experiment 
not only shows the manner in which the parts are restored, but also 
the advantage of passive motion ; for if the part be frequently moved, 
the intervening substance becomes entirely ligamentous ; but if it be 
left perfectly at rest for a length of time, ossiflc action proceeds from 
the extremity of the tibia into the ligamentous substance, and thus 
produces an ossiflc anchylosis." 

Second. Is it not probable, moreover, since the limb can be retained 
in place so much more easily after resection, that it will actually, in a 
majority of cases, be found to have been retained in place more per- 
fectly? Even after simple dislocations, especially in those occurring 
at the ankle-joint, great deformity and much maiming are the not un- 
frequent results, and that too when all diligence and care have been 
employed. It has been impossible always to maintain a perfect appo- 
sition in the articulating surfaces. How much greater must be this 
difficulty in cases of compound dislocations ! 

Third. The only argument which remains in favor of reduction 
without resection is the necessary shortening of the limb after resec- 
tion. But this need seldom perhaps to exceed three-quarters of an 
inch, and often not more than half an inch ; an amount of shortening 
which, as I have had occasion to prove when treating of fractures, 
does not necessarily produce a halt, and which indeed is often not 
known to exist by the patient himself. 

Finally. It must not be inferred that the author intends to recom- 
mend resection' as a universal practice in cases of compound disloca- 
tions of the long bones. He has only sought to determine in a general 
manner its relative value as compared with other modes of procedure ; 
and especially has it been his intention to bring more prominently 
into view the importance of rest and relaxation to the muscles, as an 
48 



746 CONGENITAL DISLOCATIONS. 

element in the treatment most essential to success. To declare its 
special application to cases would demand a treatise more elaborate 
than it was proposed to write. If, however, one were to speak of the 
individual bones only, there seems sufficient authority in the facts and 
arguments already presented to conclude that resection is applicable 
to certain compound dislocations of the clavicle, humerus, radius, and 
ulna, fingers, femur, tibia, fibula, and toes ; in short, to a certain pro- 
portion of all these accidents occurring in the long bones of the 
extremities. 

If an attempt is made to save the limb without resection, it is scarcely 
necessary to say that the success will depend, in a great measure, upon 
the care, attention, and skill bestowed upon the treatment. Cool or 
tepid water-dressings, according as the indications or the sensations of 
the patient seem to demand, are among the most valuable remedial 
agents. The limb must be maintained in a position of rest, combined 
with moderate elevation; and the bran-dressings, recommended in 
compound fractures, will be found occasionally useful. 



CHAPTEE XXVI. 

CONGENITAL DISLOCATIONS. 
§ 1. General Observations and History. 

"We have omitted, until this moment, to speak of Congenital Dislo- 
cations, because, whatever theory of causation we adopt, dissections 
have shown that they are generally, in some sense, pathologic, or are 
accompanied with such essential modifications of the anatomical struc- 
tures as to separate them entirely from ordinary traumatic luxations, 
which alone constitute the proper subjects of consideration in the pre- 
sent treatise. In relation to congenital dislocations, we shall find it 
necessary to establish systems of etiology, symptomatology, prognosis, 
and treatment, having very few points in common with traumatic dis- 
locations. Exceptions to this rule will occur, in examples of intra- 
uterine traumatic luxations, existing at birth without either original 
or accidental malformations of the articulations, or of the adjacent 
muscular, tendinous, or ligamentous structures ; yet only in sufficient 
numbers to warrant the intrusion of the subject in this place. 

It is probable that congenital displacements may occur in all the 
articulations of the skeleton ; and in most of them their existence has 
been already established by dissections. Until within a few years, 
however, the attention of surgeons has been almost entirely directed 
to congenital dislocations of the shoulder and hip. 

Hippocrates, in his treatise "De Articulis," speaks expressly of dis- 
locations of the hip occurring in the mother's womb, comprising them 
under the same order with the different varieties of club-foot. 



GEXEKAL OBSERVATIONS AND HISTORY. 747 

Avicenna and Ambrose Pare "have each mentioned original disloca- 
tions of the hip ; but the first to record an example with any degree 
of accuracy was Kerkring; in which case, death having occurred 
during infancy, he was able to verify his opinion by an autopsy. 
Chaussier has reported, in the Bulletin de la Faculte et de la Societe de 
Medecine, An. 1811 and 1812, the case of an infant, upon which he 
discovered, at birth, two dislocations, one at the scapulo-humeral arti- 
culation, and the other at the coxo-femoral. In 1788, Palletta, of Milan, 
published, under the title of Adversaria Ohirurgica, a collection of 
observations, in which, among other things, he has described certain 
congenital malformations of the hip-joint; and in 1820, he published 
another work, entitled Exercitationes Pathologies, where he enters into 
a more complete exposition of the nature and causes of these de- 
formities. 

In 1826, Dupuytren read, before the Academy of Sciences, a memoir 
upon the lameness produced by the original displacement of the 
femur; and in the Lecons Orales, published in the collections of the 
Sydenham Society, may be found a fall record of the views and obser- 
vations of this distinguished surgeon. 

The writings of Dupuytren seem, more than anything previously 
written, to have directed the attention of surgeons and pathologists to 
this interesting subject, and to have given a new impulse to investi- 
gation. 

From this time, various treaties have been written by eminent 
surgeons, many of which are characterized by profound thought, care- 
ful investigation, and practical experiment. 

Among those who have furnished us lately with elaborate treatises, 
or with more precise practical information upon this subject, the fol- 
lowing names deserve to be especially mentioned : Breschet, 1 Caillard- 
Billioniere, 2 Lehoux, 3 Sandiforte, 4 Duval and Lafond, Humbert and 
Jacquier, Bouvier, 5 Sedillot, 6 Gerdy, Poliniere, Wrolik, 7 Gruerin, 8 Pa- 
rise, 9 Pravaz, 10 Carnochan, 11 and Eobert Smith. 12 

1 Breschet, Repertoire d'Anatomie et de Physiologie. 

2 Caillard-Billioniere, These Inaugurate, 1828. 

3 Lehoux, These Inaugurate, 1834, Paris. 

4 Sandiforte, Thesis, Sustained before the Faculty of Med. of Leyden. 

5 Duval and Lafond, Humbert and Jacquier, Bouvier. See Pravaz. 

6 Sedillot, Journ. de Connais. Med.-Chirurg., 1838. 

7 Gerdy, Poliniere, Wrolik. See Pravaz. 

8 Guerin, Recherches sur les Luxations Congenitales; par Jules Guerin, Paris, 1841. 

9 Parise, Archiv. Gen. de Med., 1842. 

10 Pravaz, Traite Theorique et Pratique des Luxations Congenitales du Femur, suivi 
d'un Appendice sur la Prophylaxie des Luxations Spontanees ; par Ch. G. Pravaz, 
Lyons, 1847. 

11 Carnochan, A Treatise on the Etiology, Pathology, aud Treatment of Congenital 
Dislocations of the Head of the Femur ; by John Murray Carnochan, New York, 1850. 

12 R. Smith, A Treatise on Fractures in the Vicinity of Joints, and on Certain Acci- 
dental and Congenital Dislocations, Dublin, 1854. 



748 CONGENITAL DISLOCATIONS. 



§ 2. Etiology. 



Hippocrates sajs that the bones of the extremities may be disar- 
ticulated during intra-uterine life by falls or blows, or by injuries of 
any kind, inflicted directly upon the abdomen of the mother. 

Ambrose Pare, while admitting the efficiency of the several causes 
named by Hippocrates, believed also that the contractions of the 
womb, and violence employed by the accoucheur were occasionally 
adequate to the production of the same results. He taught, moreover, 
that the position of the foetus itself might favor the displacement; 
and that, in some instances, an articular abscess, insufficient depth of 
the socket with a laxity of the ligaments, were competent to determine 
the expulsion of the head of the femur from its natural position. 

Sedillot regards a softening and relaxation of the ligaments as the 
most frequent cause. 

Parise and Malgaigne are disposed to attribute a majority of these 
cases to hydrarthrosis, or water in the joints. Says Malgaigne : "For 
myself, after having long meditated upon this subject, I have come to 
think that inflammation of the joints enjoys a grand role, both in 
coxo-femoral dislocations and in many others, and even also in various 
congenital malformations generally ascribed to arrest of development." 
This writer admits, however, that it will not do to generalize too much 
in this matter, and that the etiology of congenital luxations is probably 
as complex as that of luxations after birth. 

Chaussier seems to have regarded muscular contraction, or the 
occurrence of an intra-uterine convulsion, as the cause of the example 
of congenital dislocation of both humerus and femur seen and recorded 
by him. Since whom Gruerin has greatly extended the application 
of this doctrine, having embraced in the same etiologic formula all 
or nearly all congenital dislocations. Guerin ascribes to muscular 
contraction in one form or another, and to corresponding muscular 
paralysis, not only dislocations of the femur and other long bones, 
but also club foot, torticollis, and various other deviations of the spine. 
He affirms, moreover, that he has established incontestably the depend- 
ence of this abnormal state of the muscular system upon the absence 
or disappearance more or less complete of corresponding portions of 
the central nervous systems. 

Breschet and Delpech maintained similar views, especially in rela- 
tion to the dependence of the several varieties of club-foot upon some 
morbid condition of the cerebro-spinal axis. While Carnochan re- 
marks as follows: "It appears most in accordance with science to 
refer the muscular spasmodic retraction, upon which congenital dis- 
locations of the head of the femur from the cotyloid cavity depend, 
to a perverted condition of the excito-motor apparatus of the medulla 
spinalis, and more especially of that portion of it which is in direct 
relation with the reflex-motor nervous fibres, distributed to the pelvi- 
femoral muscles surrounding, and in connection with, the ilio-femoral 
articulation." 

Palletta ascribes these deformities solely to an original defect of the 



CONGENITAL DISLOCATIONS OF INFEEIOE MAXILLA. 749 

germ ; and Dupuytrea also declares that, in the case of a congenital 
dislocation of the hip, the causes are coeval with the earliest organiza- 
tion of the parts, and that the displacement is due rather to a defect 
in the depth or completeness of the acetabulum, than to accident or 
disease. 

Breschet and Delpech, both of whom, as we have already stated, 
refer them to some morbid condition of the cerebro-spinal axis, ima- 
gine that in consequence of this morbid condition of the nervous 
centres, there exists an arrest of development in the bones, muscles, 
ligaments, sockets, and, in short, through all the apparatus of the joint 
which is the seat of the deformity. 

If we proceed to analyze these various opinions, we shall find that 
they are so far susceptible of classification, as that they may be 
arranged under the three following divisions. 

First the physiological doctrines; according to which congenital 
dislocations are due to an original defect in the germ, or to an arrest 
of development. 

Second, the pathologic doctrines ; which refer them to some sup- 
posed lesion of the nervous centres, to contraction or paralysis of the 
muscles, to a laxity of the ligaments, to hydrarthrosis, or to some other 
diseased condition of the articulating apparatus. 

Third, the mechanical doctrines ; which recognize no intra-uterine 
dislocations except those which are strictly traumatic. The causes 
being understood to be the peculiar position of the foetus in utero, 
violent contractions or the constant pressure of the walls of the uterus, 
falls and blows upon the abdomen, and unskilful manipulation of the 
child in delivery. 

After a full and careful consideration of this subject, we are pre- 
pared to admit the occasional agency of all the causes enumerated, 
and the probable concurrence of two or more in many instances ; nor 
do we see the propriety of rejecting, as Malgaigne has done, all that 
large class of malformations which seem to depend upon an arrest of 
development, or those which appear to be due mainly or solely to 
intra-uterine paralysis, of both of which many examples have been 
reported. 



§ 3. Congenital Dislocations op the Inferior Maxilla. 

Malgaigne affirms that " we know of no congenital dislocation of the 
jaw," and that we are "not to take seriously the pretended luxation 
observed by Guerin upon a derencephalous infant." The example 
recorded by Robert Smith he rejects also, declaring that he does " not 
comprehend how one can see in it a luxation." 

For myself, I know of no reason why we should not take " seriously" 
the case mentioned by Guerin, since, so far as appears in his very brief 
report of the same, it might have been a true luxation. The specimen 
was before the academy, and if Malgaigne, from a personal examina- 
tion, has become satisfied that a dislocation did not exist, he ought to 
have so informed us. But since he does not speak of having made it 



750 CONGENITAL DISLOCATIONS. 

the subject of especial examination, we shall feel compelled to accept 
of it as reported by Guerin. 

As to the objection offered to Mr. Smith's case, namely, that " aside 
of the complete absence of its history, the subject did not present the 
characteristic signs of luxation ; and the dissection discovered neither 
maxillary condyle, nor glenoid cavity," we must reply, the dissection 
seems to us to have furnished such evidence that the deformity was 
congenital as to render its history unnecessary ; the signs were charac- 
teristic, not indeed of a traumatic luxation, but of a congenital disloca- 
tion, such as may be supposed to have been the result of an arrest of 
development, or of an original aberration of the germ. 

The following is a summary of the very complete account of this 
case given by Robert Smith. 

On the fifth of May, 1840, Edward Lacy, set. 38, an idiot from in- 
fancy, died at the Hard wick Hospital, in consequence of gangrene of 
the lungs. "While making the autopsy, a singular deformity of the 
face was discovered. The right and left sides seemed as though they 
did not belong to the same individual, the left being in every respect 
more fully developed. Upon removing the integuments, the muscles 
of the right side were found to be much smaller than those of the left, 
and especially the masseter. These latter having been removed also, 
the condition of the right temporo-maxillary articulation was carefully 
studied. 

When the mouth was closed, the external lateral ligament, instead 
of being directed backwards, was seen descending obliquely forwards, 
to be attached to a very imperfectly developed condyle situated at 
least one-quarter of an inch iu front of its natural position. There 
was neither an inter-articular cartilage nor cartilage of incrustation, 
the joint surfaces being invested by a thick periosteum aloue ; nor was 
there any distinct capsular ligament. 

Nearly the whole of the right side of the inferior maxilla was 
smaller than the left. The condyle was short and curved, being 
directed nearly horizontally inwards, and resembling much more the 
coracoid process than the condyle of the inferior maxilla. The coro- 
noid process was very small and thin, and the sigmoid notch could 
scarcely be said to exist. 

The articular eminence of the temporal bone was absent, there being 
in its place merely a flat surface destitute of cartilage ; which surface 
presented upon its inner side a shallow and semicircular sulcus where 
the hook-like condyle of the lower jaw had played. 

The malar, superior maxillary, and sphenoid bones of the right side 
had also suffered corresponding changes of form and relative size. 

The motions permitted in the lower jaw were more extensive than 
those which it enjoys in its normal condition, that is, upon the right 
side the ramus could be removed very freely forwards and backwards, 
while upon the left, the condyle underwent a species of rotation upon 
its axis. During life the patient was observed to be constantly per- 
forming this motion, and the right side of the face was continually 
affected with spasmodic twitches. When the mouth was closed, the 



CONGENITAL DISLOCATIONS OF INFERIOR MAXILLA. 751 

front teeth of the upper jaw projected beyond those of the lower, and 
when opened the deformity was in all respects greatly increased. 1 

Mr. Smith takes this occasion also to express his dissent from the 
views maintained by Kibes, namely, that the formation of the glenoid 
cavity is consequent upon the growth of the condyle, and that, were 
this process not formed, there would not exist either a glenoid cavity 
or an articular eminence. It is true that neither the glenoid cavity 
nor the articular eminence is found in the foetus. Until the seventh 
month of intra-uterine life, there exists at this point of the temporal 
bone only a plane surface, and the glenoid cavity with its correspond- 
ing eminence is developed in proportion to the growth and develop- 
ment of the condyle. But Mr. Smith justly observes that although 
the development of the condyle does precede that of the glenoid 
cavity, "it by no means follows that the formation of the latter is due 
to the pressure of the former." The cavity, or rather the transverse 
eminence in front of the plane surface, does not exist in foetal life, 
because, owing to the peculiar form of the inferior maxilla at this 
period, its existence is not necessary. The vertical portion of the jaw 
(vertical only in the adult) is in the foetus nearly in the same line with 
the axis of the shaft, and consequently when the mouth is opened by 
the action of the muscles, the condyles are pressed upwards and back- 
wards instead of upwards and forwards, as in the adult. A diplace- 
ment forwards cannot therefore very well occur ; and the protection 
of the articular eminences is not required. As age advances the 
angles of the jaw increase, the portions upon which the condyles rest 
become more vertical, and finally a displacement forwards would occur 
whenever the mouth was well opened if the articular eminences were 
not present to afford a sufficient protection in front. 

In the case of Lacy the foetal condition of the bones upon one side 
remained during life, there being neither cavity nor eminence, and 
the condyle itself being only imperfectly developed ; but the angle of 
the jaw had assumed the form which belongs to the adult, and the 
ascending ramus was vertical, consequently the condyle became some- 
what displaced forwards. 

Chronic rheumatic arthritis is occasionally found in the temporo- 
maxillary articulation of old persons ; and it may be important to 
distinguish it from congenital luxation, with which, owing to the ab- 
sorption of the articular eminence, and the consequent displacement 
of the condyle, it might possibly be confounded. 

Says Mr. Smith: "In a majority of instances, this remarkable dis- 
ease attacks those of advanced age, and is symmetrical ; but occasion- 
ally it occurs during the period of adult life. In the latter case it is 
generally more rapid in its progress, is accompanied by greater pain, 
and is more liable to implicate the neck of the condyle, and the ramus 
of the jaw." 

When the condyle is implicated it becomes enlarged, and can be 
felt beneath the zygoma, in front of the meatus externus. The lym- 
phatic glands of this region are sometimes enlarged, and the progress 

1 Robert Smith, op. cit., p. 283. 



752 CONGENITAL DISLOCATIONS. 

of the malady is attended with a constant but not generally severe 
pain. 

The deformity of the face varies according as one or both articula- 
tions are affected. When the malady is confined to one joint, the chin 
is thrown slightly forwards, but chiefly to the opposite side ; and when 
both are implicated the chin is simply advanced so that the teeth pro- 
ject beyond those of the upper jaw. 

As the disease progresses, the glenoid cavity enlarges by absorp- 
tion, and at length a considerable portion or the whole of the articular 
eminence disappears, and the jaw becomes gradually displaced through 
the action of the external pterygoids. The disease does not extend 
in the temporal bone beyond the articulating surface of the glenoid 
cavity. The condyle assumes a variety of forms, sometimes being 
greatly enlarged in all its diameters, while its upper surface may be 
flattened, or conical. The inter-articular cartilage disappears; but 
Mr. Smith has never yet found any foreign bodies in the joint, and in 
only one instance have the surfaces been polished or eburnated as we 
often see in examples of chronic rheumatic arthritis occurring in the 
hip, knee, and other joints. 

The following is an excellent summary of the diagnostic marks 
between congenital, accidental, and rheumatic dislocations, given by 
this writer : — 

" 1. In the congenital luxation, the mouth can be freely opened and 
closed ; in chronic rheumatism these motions can be performed, but 
not without uneasiness to the patient, an uneasiness which sometimes 
amounts to severe pain ; in luxations from accident, the mouth cannot 
be closed. 

"2. An involuntary flow of saliva accompanies the accidental luxa- 
tion alone, although in some cases of chronic rheumatism there is an 
increased secretion of that fluid. 

"3. In congenital luxation, the teeth of the upper jaw project be- 
yond those of the lower ; the reverse is observed in accidental luxa- 
tion and in chronic rheumatism. 

"4. In congenital luxation there is no fulness in the cheek, such as 
the coronoid process produces in cases of accidental luxation, and the 
condyle is not enlarged, as in some instances of chronic rheumatic 
arthritis." 1 

§ 4. Congenital Dislocations of the Spine. 

Says Gruerin, of the subluxation occipito-atloidean there are two 
varieties: "First. Backwards, consisting in an exaggerated flexion of 
the head upon the front of the neck and chest, with a commencement 
of sliding backwards of the occipital condyles upon the articular 
facets of the atlas. Here are two examples in foetal enencephalous 
monsters. Second. Forwards. Those who follow my consultations 
can recollect having seen last year an infant, about two or three 
months old, who offered a remarkable example. The head was ex- 
actly applied against the posterior part of the neck, and upper part 

i R. Smith, op. cit., p. 292. 



CONGENITAL DISLOCATIONS OF THE STERNUM. 753 

of the back. There was probably a sliding of the condyles forwards, 
with elongation of the anterior ligaments." 1 

The existence of the first of these varieties has since been denied 
by Guerin himself; 3 and it will be noticed that he only speaks of the 
second as a, probable subluxation forwards. Neither of them can there- 
fore be regarded as established. 

Guerin farther remarks that he has observed subluxations in the 
other regions of the spinal column many times ; and he showed to the 
Academy a foetus in which the spine presented, besides the occipito- 
atloidean displacement, a series of angular flexions in the anteropos- 
terior direction, with sliding of the articular surfaces. 

In attempting to appreciate the value of Guerin's observations upon 
this point, it must be remembered that he regards all cases of congeni- 
tal torticollis, and other deviations of the spine, as examples of sub- 
luxation ; and, in some sense, we think the theory of this distinguished 
surgeon may be regarded as correct. The amount of articular dis- 
placement between each of the adjacent vertebras may be very incon- 
siderable in any such case, yet, however trivial, if it exceeds the limits 
of natural motion, it may properly enough be regarded as the com- 
mencement of a luxation. 



§ 5. Congenital Dislocations op the Pelvic Bones. 

Bassius speaks of a diastasis or separation of the sacro-iliac sym- 
physis, observed by him in newly-born children, and in infants ; but, 
according to Malgaigne, his account of these cases is not such as to 
warrant any conclusions as to the true nature of the displacements. 

Congenital extrophy of the bladder is accompanied always with a 
deficiency of the central and upper portions of the pubic bones, the 
result manifestly of an arrest of development; but these cases, of 
which I have seen three examples, are not properly examples of con- 
genital dislocations, but only of diastases, the separated portions re- 
maining in their normal position with reference to each other except 
that they are not prolonged sufficiently to meet in the median line. 

Guerin declares, however, that he has seen congenital displacement, 
or overriding of the iliac bone upon the sacrum, accompanied with 
coxo-femoral dislocation and curvature of the spine. The same writer 
mentions an example, in a foetal monster, of diastasis of the pubic 
bones, and of the sacro-iliac symphysis, accompanied with a turning 
out of the pubes upon the external face of the ischium. 3 

§ 6. Congenital Dislocations of the Sternum. 

Seger alone has reported one example of luxation of the xiphoid 
cartilage from the sternum. 

A woman in her fifth month of pregnancy fell and dislocated her 
shoulder. Just four months after this she was brought to bed with 

i Guerin, op. cit., 1841, p. 29. 2 Ibid., Gaz. Med., 1851, p. 227. 

3 Ibid., op. cit., p. 32. 



754 CONGENITAL DISLOCATIONS. 

an infant, well formed, except that, soon after it was born, the ensiform 
cartilage was observed to be remarkably movable, especially when the 
child hiccoughed, to which it was very subject. The cartilage was 
separated from the sternum by the breadth of the little finger. No 
treatment was employed ; the cartilage gradually became restored to 
its place, and in about one year it was firmly united to the sternum. 1 

§ t. Congenital Dislocations of the Clavicle. 

Malgaigne says that a congenital dislocation at the sternoclavicular 
articulation has never been observed ; but Guerin declares that he has 
established the existence of three varieties, namely: — 

1. A luxation of the sternal end of the clavicle inwards and for- 
wards; this extremity of the clavicle lying in front of the sternal 
fourchette. In illustration of which he presented to the Academy a 
plaster cast of a girl eight years old, in whom the displacement existed 
upon both sides. 

2. Inwards and upwards. Observed by him in a girl eight years 
old; but which displacement took place only when the arm was 
moved, and through the contraction of the sterno-cleido-mastoideus 
muscle. 

3. Backwards. Of which he presented two examples in the cor- 
responding sides of a foetal monster. 

I believe I have already referred to Fergusson's case of dislocation 
of the sternal end of the clavicle forwards, which occurred during 
birth. The end rested in front of the sternum, and could be pushed 
into its place with great ease; but when left alone it immediately 
slipped out again. Nothing was done, a new joint formed, and the 
child afterwards possessed as much power in the one arm as in the 
other. 2 

Guerin says that he has seen a dislocation upwards and outwards at 
the acromial end of the clavicle in a foetus of three months. 

In regard to the treatment of either of these displacements of the 
clavicle, we need only remark that a reduction ought to be attempted ; 
and, if practicable, without much confinement of the little patient, it 
should be maintained until the bones have become fixed in their 
natural positions. It is quite probable that this can never be accom- 
plished, at least perfectly ; but it will nevertheless be proper always 
to make the attempt. 

§ 8. Congenital Dislocations of the Shoulder. {Upper End of the 

Humerus.) 

Guerin affirms that he has established the existence of three varie- 
ties of scapulo-humeral dislocations, namely : — 

1. Dislocations of the head of the humerus downwards; of which 
variety he presented to the Academy a plaster cast taken from a boy 

1 Seger, Ephem. Nat. Curios., 1677, from Malg., op. eit., p. 410. 

2 Fergusson, System of Surg., 4th. Amer. ed., 1853, p. 203. 



CONGENITAL DISLOCATIONS OF THE SHOULDEE. 755 

ten years old. The displacement existed in both arms, but much 
more pronounced in the right than in the left arm. It was due wholly 
to paralysis of the muscles about the joint, and to elongation of the 
capsule. 

2. Downwards and inwards; complete upon one side and incom- 
plete upon the other, in the same person. The head of each humerus 
was applied against the ribs, and the arms maintained in an abduc- 
tion almost horizontal, under the influence of the retraction of the 
deltoid-muscles. " The same case," Guerin remarks, " has been con- 
firmed by Koux." 

3, Subluxation upwards and outwards: seen on both sides in a 
foetal monster, which was offered to the Academy for examination ; 
and in one arm of a young man fifteen years old, of which Guerin 
presented a plaster cast. " It is characterized by a sliding of the head 
of the humerus in the direction indicated ; this sliding being favored 
by a corresponding displacement of the coracoid and acromion pro- 
cesses." 1 

Malgaigne, who regards " all luxations in consequence of paralysis 
as essentially posterior to birth," will not admit the first example 
mentioned by Guerin ; but, as we stated before, the objections made 
by Malgaigne have failed to convince us of the propriety of rejecting 
all of this class of reported examples. Of the second case, mentioned 
by Guerin as having been confirmed by Roux, Malgaigne declares 
that he has consulted Roux upon this matter, and that he affirms that 
"he has never seen a congenital luxation of the shoulder." 

Robert Smith has met with but two of the forms of congenital 
luxation of the humerus described by Guerin, namely, that in which 
the head of the humerus is displaced forwards, and that in which it 
is displaced backwards. Of the first variety he has seen several ex- 
amples. 

The first was in the person of Alexander Steele, set. 29, who pre- 
sented both a dislocation of the head of the humerus under the cora- 
coid process of the left scapula, and pes equinus in the foot of the left 
leg. The muscles of the arm and shoulder upon that side were feeble 
and greatly atrophied. The humerus was shortened ; its head being 
of the natural size and form, but when the arm hung by the side it 
dropped so far from its socket as to permit the thumb to be placed 
between the head and the acromion process. By pressing the hume- 
rus forwards the finger could be placed in the outer part of the glenoid 
cavity ; and, although the head could be moved about thus freely, it 
seemed naturally to occupy only the anterior half of the glenoid 
fossa. 

Robert Smith's second example of subcoracoid congenital luxation 
was presented in the person of Mr. EL, set. 20, the condition of whose 
left shoulder resembled almost precisely that of Mr. Steele. "The 
deformity had existed from his birth, but became much more obvious 
and striking as he increased in age and stature." 

In the third example the child had attained nearly the age of one 

1 Guerin, op. cit., p. 30. 



756 CONGENITAL DISLOCATIONS. 

year before the condition of the limb attracted attention, which was 
then excited, not by the deformity of the shoulder, but by the atro- 
phied condition of the muscles of the arm. The child had never 
complained of pain about the joint, nor had he ever met with any ac- 
cident. No doubt this also was an example of paralysis, and it is not 
improbable that it was congenital, but the evidence upon this point is 
not very conclusive. When seen by Mr. Smith, he was nine years 
old, the shoulder and arm presenting the same appearance as in the 
other cases mentioned. 

The fourth was also subcoracoid and symmetrical, the same defor- 
mity existing in both shoulders. This was in the person of a female, 
set. 21, who had been' for many years a patient in a lunatic asylum, 
and who died of chronic inflammation of the meninges of the brain. 

Mr. Smith, who himself made the autopsy, first noticed the condi- 
tion of the left shoulder. The muscles were atrophied ; the head of 
the humerus could be felt lying under the coracoid process; the elbow 
projected from the side, but could be readily brought into contact 
with it. The right shoulder presented the same appearance, but the 
deformity was somewhat less, and the head of the humerus was not 
so directly underneath the coracoid process. 

From the external appearances presented by the two shoulders, Mr. 
Smith did not doubt that these deviations from the natural state of 
the parts were not the result of violence. 

Proceeding to remove the soft parts upon the left side, scarcely any 
trace was found of a glenoid cavity in its natural situation, but im- 
mediately underneath the coracoid process, upon the costal surface of 
the scapula, was formed an oblong socket completely surrounded by 
a capsular ligament, which ligament included also that small portion 
of the original socket which remained. The head of the humerus 
was changed in form, being oval, and fitted, in some measure, to both 
the old and new sockets upon which it seemed to rest alternately. 

Upon the right side, although the condition of the bones was some- 
what different, the characteristic features of the deformity were similar. 

Malgaigne, who quotes Mr. Smith as saying that these dislocations 
must have been congenital, and for no other reason than because they 
were symmetrical, has scarcely done this author justice. Says Mr. 
Smith: "The position of the glenoid cavity, the remarkable form of 
the head of the humerus, the presence of a perfect glenoid ligament, 
the absence of any trace of disease, and the existence of the defor- 
mity upon each side, all indicate the original nature of the malforma- 
tion." 

The only example of backward luxation seen by Mr. Smith was 
also symmetrical, and seems to be equally well authenticated. This 
was in the person of a woman named Doyle, ast. 42, a lunatic also, 
who died Feb. 8, 1839, in Dublin. She had been a patient in the 
lunatic asylum fifteen years, and was subject to severe epileptic con- 
vulsions, which ultimately proved fatal. 

Mr. Smith made the autopsy on the day following her death. The 
convolutions of the brain were small and atrophied, as is frequently 
observed in idiots. 



CONGENITAL DISLOCATIONS OF THE SHOULDER. 757 

The two shoulders resembled each other so perfectly, both in ex- 
ternal appearance and in their anatomy, that Mr. Smith has only 
found it necessary to describe particularly the condition of one. 

The coracoid process was remarkably prominent, but the acromion 
was not so prominent as in accidental dislocations of the shoulder. 
The head of the humerus could be seen and felt distinctly moving 
with the shaft, upon the dorsal surface of the scapula. On removing 
the integuments, muscles, &c, no trace of a glenoid cavity was found 
in its natural situation ; but upon the external surface of the neck of 
the scapula was a well -formed socket, which received the head of the 
humerus. This socket was covered with a cartilage of incrustation, 
and surrounded by a perfect capsule. The tendon of the biceps arose 
from the top and internal margin of the socket. The form of the 
acromion process was changed ; the capsule smaller than natural ; the 
head of the humerus irregularly oval, its anterior half alone being 
in contact with the glenoid cavity ; the great tubercle natural, but the 
lesser was elongated and curved, forming a process of an inch in 
length, around the base of which the tendon of the biceps muscles 
played. 1 

Gaillard relates the case of a female child, upon whom the left arm 
was discovered to be deformed a few days after birth, and the elbow 
separated from the side. Later, the arm was found to be nearly im- 
movable, and only at the end of four years was the dislocation recog- 
nized; but no attempt at reduction was then made. When sixteen 
years old, she was seen by Gaillard, who found the head of the hume- 
rus in the infra-spinous fossa. The scapula, clavicle, and arm were 
preternaturally small; the forearm, although well developed, could 
not be completely extended nor supinated. 

Despite these unfavorable circumstances, Gaillard determined to 
make an attempt to accomplish the reduction. Four times in the space 
of eight days he submitted the arms to extension made at right angles 
with the body, by means of sixteen pound weights, the extension being 
continued from twenty to twenty-five minutes, and occasionally his 
own exertions being added to the weights. On the fourth attempt, 
the head of the bone was drawn gradually forwards, and by a rotatory 
motion it was finally made to slip into its socket; but.it became im- 
mediately displaced. The next day Gaillard reduced it anew, and 
retained it in place one hour. Six days later it was again reduced, 
and, by the aid of bandages, permanently retained in place. The 
slight pain and swelling which followed soon disappeared ; and by the 
aid of careful exercise, at the end of two years the arm had increased 
in length, and the patient could use the arm and hand so much better 
than before, as to encourage a hope that the recovery would be com- 
plete. 2 

Aristide Eodrigue, of Hollidaysburg, Penn., in a letter to the editor 
of the American Journal of Medical Sciences, gives the following brief 

1 Robert Smith, op. cit. 

2 Gaillard, Mem. de l'Acad. de Med., 1841, from Malg., p. 569. 



758 CONGENITAL DISLOCATIONS. 

account of a case of intra-uterine dislocation of the shoulder, compli- 
cated with a fracture of the forearm. 

"The woman, when about four months gone with child, fell on her 
left side, striking a board, and felt herself much hurt at the time : at 
the full period she was delivered of a full-grown large boy with the 
following deformity: dislocation of the humerus into the axilla; frac- 
ture of both bones of the forearm of left side, lower third. Dislocation 
could not be reduced ; union of the bones of the forearm by ossific 
matter complete; bones passing each other, and hand at an angle of 
about 40°; the child did well otherwise; now, four years old, strong 
and healthy; humerus has grown nearly apace with the other; forearm 
has not, and remains short and deformed as in birth; the hand is of 
the same size with that of the sound side." 1 

§ 9. Congenital Dislocations of the Radius and Ulna Backwards. 

It is not uncommon to meet with examples of a slight subluxation 
backwards of these bones in feeble and newly-born infants ; which 
condition is probably due to a relaxation and elongation of the cap- 
sule. It is characterized by a preternatural mobility of the joint, and 
especially by the circumstance that the limb is capable of abnormal 
extension, or flexion backwards, as it is sometimes called. Gruerin has 
seen this condition more advanced, the bones of the forearm having 
actually overlapped somewhat upon the lower end of the humerus, so 
that the articular surface of this latter presented itself in the fold of 
the elbow. This was especially observed in a girl of fourteen and a 
boy of thirteen years, and also in the two arms of a foetal monster. 2 

Chaussier relates that a young woman, at the commencement of the 
ninth month of pregnancy, perceived suddenly movements of the foetus 
so violent that she almost lost her consciousness. These movements 
were repeated three times in the space of six minutes, after which 
everything returned to its natural order, and the accouchement took 
place naturally and at the usual term. The infant was pale and feeble, 
and presented a complete backward luxation of the radius and ulna. 3 

§ 10. Congenital Dislocations of the Head of the Radius. 

Examples of this luxation have been reported by Dupuytren, Cru- 
veilhier, Sandiforte, Adams, Dubois, Yerneuil, Deville, Robert Smith, 
and Guerin, most of which were in the direction backwards, some 
outwards, but only one of them forwards; some were double, the same 
deformity being presented in both arms, and others were single. In 
a few examples the dislocations were complicated with a consolidation 
of the radius to the ulna, and in others with a deficiency of the ulna 
or with some deformity indicating its congenital origin. 

Of the symmetrical or double dislocation backwards Dupuytren 
furnishes the following example, presented to him in 1830, by M. 

1 Rodrigne, loc. cit., Jan. 1854, p. 272. 

2 Guerin, op. cit., p. 31. 3 Chaussier, from Malgaigne, op. cit., t. ii. p. 268. 



CONGENITAL DISLOCATIONS OF THE WRIST. 759 

Loir: "The abnormal position which the head of either radius had 
assumed was at the back part of the lower extremity of the humerus, 
beyond which it extended for the .space of at least an inch. This 
disposition of parts was absolutely identical on the two sides, and had 
all the characters of a congenital affection." 1 

In Jan. 1866, John Fitz morris, aet. 19, was admitted to the Bellevue 
Hospital, laboring under a general scrophulous cachexy, in whose 
person I found a congenital dislocation of the heads of both radii, out- 
wards. The luxations are complete. The ulnse are in place and of 
natural form, but their articulations at the wrist are loose. The same 
remark applies to all the other joints in the body. The power of pro- 
nation and supination is unimpaired, as well, also, as the power of 
flexion and extension. 

In the example of outward luxation, mentioned by Deville, there 
was an almost complete absence of the ulna, the head of the radius 
mounting upwards more than three centimetres above the level of the 
articulation. 2 

Guerin, who has described the only example of a forward luxation, 
says it was observed by him in a girl of seven years, and that it was 
symmetrical. The two radii lay in front of the humeri near the coro- 
nary fossettes. 3 

§ 11. Congenital Dislocations of the Wrist. 

Guerin thinks he has seen three forms of congenital luxation of the 
wrist. First, a dislocation forwards characterized by a sliding of the 
wrist before the bones of the forearm, and by the projection posteriorly 
of the lower ends of the radius and ulna ; seen in an infant of six 
months, and in two adults. Second, backwards and upwards ; seen 
in a child of six years, and accompanied with an incomplete paralysis 
of all the muscles of the forearm and hand. Third, backwards and 
outwards ; in a girl of fourteen years, accompanied with incomplete 
paralysis. 4 

Guerin has also seen three examples of dislocation outwards in 
foetal monsters, and one of dislocation inwards, as the result of arrest 
of development. 

Eobert Smith believes that the case of simple dislocation of the 
wrist or of the carpus forwards ; mentioned by Cruveilhier in his 
Anatomie Paihologique, was an example of congenital luxation; and he 
relates two other cases equally remarkable which came under his own 
observation. One was in the person of Deborah O'JSeil, a lunatic and 
epileptic, who died when thirty-six years old. Both upper extremities 
were deformed from birth ; the right presenting an example of dislo- 
cation of the carpus forwards, and the left of dislocation of the carpus 
backwards. The dissection showed that there had been an arrest of 
development, especially in the bones of the forearm and carpus. The 

1 Dupuytren, Injuries and Dis. of Bones, p. 117. 

2 Deville, Bulletins de la Soc. Anat., 1849, p. 153. 

3 Guerin, op. cit., p. 31. 

4 Ibid., p. 717. 



760 CONGENITAL DISLOCATIONS. 

second was in the person of a young woman who died of phthisis in 
the Eichmond Hospital ; the right wrist presenting an example of 
congenital dislocation of the carpus forwards from arrest of develop- 
ment also. 1 

Marrigues describes a very singular congenital displacement which 
he found upon a newly-born infant. The radius and ulna were widely 
separated below, and in the interspace was lodged the whole of the 
first range of the carpal bones; the hand being strongly turned in- 
wards. 2 

§ 12. Congenital Dislocations of the Fingers. 

Chaussier found in a foetus the last three fingers of the left hand 
dislocated at the metacarpophalangeal articulation. The thighs, knees, 
and feet were also dislocated. 3 

A. Berard speaks of an incurvation backwards of the last two pha- 
langes of the fingers as having been occasionally seen in newly-born 
children of the female sex ; and Malgaigne adds that he has himself 
seen a woman who had, from birth, all the phalangettes carried back- 
wards to an angle of 135°, leaving the heads of the phalanges project- 
ing forward under the skin. 4 

Eobert has seen, in a girl six years old, a congenital lateral luxation 
of the phalangette of the index finger, which was inclined outwards at 
an obtuse angle. The external condyle of the lower extremity of the 
proximal phalanx was slightly atrophied, and the internal presented a 
corresponding projection. Eobert cut the internal lateral ligament by 
a subcutaneous incision, but without any favorable result. 5 

§ 13. Congenital Dislocations of the Hip. 

Dupuytren thought that double dislocations of the hip-joint, as 
congenital accidents, were more common than single dislocations, but 
in the experience of Pravaz the rule has been reversed, he having met 
with but four double dislocations in a total of nineteen. 

Congenital dislocations of the femur have been noticed much oftener 
in females than in males. Of forty-five examples mentioned by Du- 
puytren and Pravaz, only seven or eight were males. 

They may be complete or incomplete. Of the complete luxations, 
four varieties have been noticed. 

Upwards and backwards, upon the dorsum ilii. This variety is by 
far the most common. 

Upwards and forwards; the head of the femur resting upon the 
eminentia ilio-pectinea. 

Downwards and forwards into the foramen thyroideum ; of which 
variety Chaussier alone mentions one example ; but Delpech found in 

1 R. Smith, op. cit., pp. 238, 251. 

2 Marrigues, Malgaigne, from Journ. de Med., 1775, t. ii. p. 31. 

3 Chaussier, Malgaigne, op. cit., t. ii. p. 751. 

4 Berard, Malgaigne, op. cit., p. 773. 5 Robert, from Malg., op. cit., p. 773. 



CONGENITAL DISLOCATIONS OF THE HIP. 761 

an infant, born paralytic., the head of the femur lodged habitually near 
the foramen thyroideum. 

Directly upwards; seen by Gruerin, Pravaz, and others; the head 
of the femur being placed immediately without the anterior inferior 
spinous process of the ilium. 

Grudrin has observed, moreover, a single variety of subluxation; 
characterized by the incomplete displacement of the head of the femur 
in the direction upwards and backwards, so that it rested upon the 
edge of the cotyloid cavity : " Observed often in newly-born children, 
and with those in whom the muscular dislocations are effected sponta- 
neously after birth." 

Through the courtesy of Dr. Davis, of this city, I was permitted in 
*March, 1865, to see a child, the daughter of a gentleman residing in 
Victor, Monroe Co., N. Y., who was born in 1860, with dislocation of 
both knees and both hip-joints. The legs at the time of birth were 
doubled forward upon the thighs, the heads of the tibias resting upon 
the front of the femurs, one inch above the condyles, the thighs being 
at right angles with the body and the feet touching the abdomen. The 
knees were drawn closely together. The dislocation of the heads of 
the femurs was not at this time recognized. By constant pressure Dr. 
J. B. Palmer had succeeded at the end of one year, in restoring the 
legs to position, the thighs remaining flexed; but when two years 
old she began to walk with her body bent forwards. The displace- 
ment of the hip-bones was then first discovered. When four years 
old the sartorius and tensor vagina3 femoris were severed, but with 
very little benefit. At the time of my examination she was five years 
old. The thighs were still flexed and adducted ; by pressure upon the 
knees the femurs could be slid upwards and backwards upon the ilium 
one inch : on rotating the femurs the trochanters were observed to 
move upon a very short radius, indicating the entire absence of head 
and neck. She walked with the gait peculiar to these conditions. 

Both Delpech and Guerin have called attention to two varieties of 
what the latter terms pseudo-luxations ; of which the first simulates 
a dislocation upwards and backwards, and the second a dislocation 
downwards and forwards. In these examples, the extreme adduction 
or abduction of the thighs might lead to a belief that the bones were 
dislocated, when in fact the abnormal position of the limbs is due 
only to muscular contraction, without actual articular displacement. 

In the remarks which follow we shall have special reference to that 
form of congenital dislocation of the femur in which the head of the 
bone rests upon the dorsum ilii, as being that which will be presented 
in a vast majority of cases, and which, characterized by the same 
general phenomena, may be regarded as typical of all the others. 

Symptomatology. — First. When the dislocation is double. 

In these examples the deformity is often found to be symmetrical ; 
the opposite limbs being precisely the same length, and in the same 
relative positions ; a circumstance which, when it exists, may render 
the diagnosis more difficult, or may cause it to be for a long time 
entirely overlooked. It is in such cases especially that the deformity 
is not usually discovered until the child begins to walk. 
49 



762 CONGENITAL DISLOCATIONS. 

The first circumstance which would naturally arrest our attention 
if the person who is the subject of this double dislocation is stripped 
and placed erect before us, is the great apparent length of the arms 
and of the body in comparison with the lower extremities. We may 
next observe that the great trochanters are carried upwards and back- 
wards, so as to make a remarkable projection in this direction ; the 
lumbar portion of the spinal column is thrown very much forwards, 
and the dorsal portion backwards. The thighs incline inwards, so as 
almost to cross each other ; the whole of the lower extremities are 
imperfectly developed and feeble ; the toes are generally pointed di- 
rectly forwards, or they may be noticed to turn inwards. 

When the person stands, and his limbs are not in motion, the heel- 
is usually brought down fairly to the floor; but in walking, and 
especially in the attempt to run, he touches only the balls and toes of 
his feet. " When they are about to walk," says Pravaz, " we see them 
lift themselves upon the points of the feet, to incline the superior part 
of the trunk toward the member which is about to support the weight 
of the body, and to lift the other from the ground with an effort, in 
order to carry it forwards. At this moment one of the trochanters, 
that which corresponds to the column of sustentation, appears to 
approach the iliac crest more nearly than when the patient is standing 
upon his two feet." In consequence of which mobility of the thigh- 
bones, the patient assumes a peculiar waddling gait, which is not only 
ungraceful but exceedingly fatiguing. 

The difficulty, of progression is, however, very variable in different 
persons. Sometimes the patient requires no aid whatever, and at 
other times he cannot walk without assistance. Generally it increases 
with age. It is especially deserving of notice that in rapid progression 
the mobility of the heads of the femurs is appreciably less than in 
slow progression, which is explained by the more constant and vigor- 
ous contraction of the muscles about the joint, when the motions of 
the limb are rapid. 

In the recumbent posture, the thighs may be drawn down easily to 
almost their natural positions. The only exception to this rule, accord- 
ing to Carnochan, " is when the head of the femur has escaped from 
the natural capsule in which it was originally inclosed, and a new 
socket has been formed upon the dorsum of the ilium." 

Abduction is performed with difficulty; adduction and rotation, 
especially inwards, being less restricted. 

Second. When the dislocation is only upon one side. 

In these cases the symptoms are essentially the same as in the double 
dislocation ; with only such slight differences and peculiarities as would 
naturally suggest themselves to the surgeon, and which will not, there- 
fore, demand from us a special consideration. 

Pathology. — The head of the femur is sometimes merely changed in 
form and consistence, the neck also undergoing corresponding altera- 
tions in its size, form, direction, &c. ; at other times the head is absent 
altogether, and with it a considerable portion, or the whole of the neck 
has disappeared. 

The pelvic bones are usually more or less deformed. The acetabu- 



CONGENITAL DISLOCATIONS OF THE HIP. 763 

him ma} 7- be entirely deficient, or it may present itself as an irregular 
bony protuberance, without cartilage, fibro-cartilage, or ligaments. 
Sometimes it exists as an oval or triangular cavity, which is expanded 
at its superior and posterior margin into a distinct fossa, where the 
head of the femur, descending from the dorsum ilii, occasionally rests. 
A new cavity is formed usually upon the side of the pelvis, which is 
shallow and without an elevated margin, or it may be deeper, and more 
complete in its construction, by the addition of an osseous border. In 
either case, the new socket is often lined with a true periosteum and 
synovial membrane ; but not unfrequently it is unprotected by any 
soft tissue, the surface being hard and polished like ivory. 

The head of the femur, having escaped from its original capsule, 
through a button-like opening, rests in this socket constantly. In still 
other examples the head of the femur remains within its capsule, and 
may be observed to play backwards and forwards between the two 
sockets ; or the head and neck being absorbed, and the capsule remain- 
ing entire, the latter is converted into a long narrow sac, somewhat 
contracted in its centre, or finally into a firm ligamentous cord, which 
being attached to the stunted upper extremity of the femur, limits its 
motions in the direction of the crest of the ilium. In this case no new 
socket is formed. 

A portion of the pelvi-femoral muscles are contracted, in conse- 
quence of an approximation of their points of origin and insertion, and 
remaining in a state of comparative, if not absolute, inertia, they 
become atrophied, or pass into a condition of fatty degeneration, while 
other muscles, in consequence of the increased labor which they have 
to perform, become hypertrophied, or degenerate into a fibrous tissue. 

Treatment. — Says Dupuytren : " Of what possible utility can it be to 
practise extension of the lower extremities in these cases, even sup- 
posing the limbs could be thus brought to their natural length ? Is 
it not evident that the head of the femur, finding no cavity fitted to 
receive and hold it, would, when abandoned to itself, resume its former 
abnormal position ? There is something more rational and feasible 
in adopting a palliative course of treatment. When we call to mind 
the natural proneness which the heads of thigh bones have to ascend 
to the external iliac fossae, and that this tendency is partly due to the 
superincumbent weight of the body, and in part to muscular action, a 
just conception may be formed of the indications on which the employ- 
ment of palliative remedies should be founded. The object should be 
to relieve the lower limbs of the superincumbent weight, on the one 
hand, and on the other to moderate the muscular action. Both of 
these indications are in part fulfilled by repose; and the attitude most 
conducive to this effect is the sitting posture, in which the weight of 
the upper part of the body is not transmitted to the lower extremities,. 
but is centred in the tuberosities of the ischia. Therefore, laboring 
persons afflicted with this infirmity should be recommended to adopfr 
a sedentary occupation, as a calling which requires much standing and 
walking about would dangerously aggravate their deformity. Yet 
one would scarcely be willing to condemn such individuals to per- 
petual repose ; and to avoid this it is necessary to discover some means 



764 CONGENITAL DISLOCATIONS. 

for diminishing the inconveniences which attend the upright posture, 
the act of walking and other exercises. Experience has taught me 
hitherto but two methods of obtaining this important object: the first 
consists in the daily employment of a perfectly cold bath, in which 
all the body should be immersed for the space of three or four min- 
utes, the head being protected by an oiled-silk cap ; the water may be 
fresh or salt ; and the only precautions necessary to take are to avoid 
bathing when the body is in a state of perspiration, or when the cata- 
menial discharge is present. These baths have a local, as well as 
general, tonic effect. The second method consists in the constant use, 
at least during the day, of a belt, which embraces the pelvis, fitting 
closely over the great trochanters, and keeping them at a constant 
height, so as to bind the parts together, and prevent that continual 
unsteadiness of the body which results from the loose connections of 
the heads of the thigh bones. For the proper fulfilment of these in- 
dications, certain precautions are necessary in the construction of this 
cincture ; in the first place, it should occupy the narrow interval be- 
tween the crest of the ilium and great trochanters, completely filling 
this space, and therefore being about three or four fingers' breadth, 
according to the age and size of the patient. It should further be 
well padded with wool or cotton, and covered with doe-skin, so that 
it may not abrade the parts to which it is applied ; and there should 
be a piece let in on either side, so as to receive and support the tro- 
chanters without entirely covering them ; it should be buckled behind, 
and padded straps be carried under the thigh, and across the tuberosity 
of the ischium, on either side, to prevent the zone from slipping up. 
I do not mean to assert that I have ever succeeded in completely get- 
ting rid of the inconveniences of congenital dislocations of the thigh- 
bones, but I have prevented their increasing, and have rendered 
supportable what I could not cure. The testimony of some patients 
to the value of this treatment has been of a most unequivocal charac- 
ter ; for being worried by the pressure of the belt, they have laid it 
aside, but have speedily restored it again, as they found that without 
it they had neither a sense of firmness in the hip, nor confidence in 
walking." 

In relation to which opinions the same excellent writer subsequently 
made the following candid admission : "I at first thought that no 
benefit would be derived in these cases from the employment of con- 
tinual traction on the lower extremities, for reasons already stated : 
but the experiments of MM. Lafond and Duval tend to throw some 
doubt on the correctness of this conclusion. These distinguished 
practitioners tested the influence of extension, in their orthopaedic in- 
stitution, on a child eight or nine years of age, who was the subject 
of double congenital dislocation of the hip ; after the uninterrupted 
employment of this treatment for some weeks, I satisfied myself that 
the limbs had resumed their natural length and direction ; but I was 
not a little astonished to find that, after extension had been persisted 
in for three or four months continuously, the greater part of the bene- 
ficial results remained for several weeks undiminished. It would be 
idle, it is true, to generalize on this single case ; but as an isolated 



CONGENITAL DISLOCATIONS OF THE HIP. 765 

example of the utility of extension it is interesting, and it may be the 
forerunner of more important results." 1 

Since which time Humbert and Jacquier, who, as well as Duval 
and Lafond, confined themselves to the treatment of deformities, claim 
to have met with equal success in the management of these cases by 
extension alone ; and, still more lately, Guerin, of Paris, and Pravas, 
of Lyons, by the adoption of the same general principle more or less 
modified, have added new triumphs, and greatly enlarged its applica- 
tion. 

The means recommended and practised by Guerin, are : first, pre- 
paratory extension destined to elongate the muscles as much as possi- 
ble ; second, subcutaneous section of the muscles which mechanical 
extension has not sufficiently elongated ; third, extension of the liga- 
ments, and even, if extension does not suffice, their subcutaneous sec- 
tion ; fourth, manoeuvres destined to effect reduction; fifth, treatment 
designed to consolidate the reduction, and consisting in the applica- 
tion of the apparatus proper to maintain the extension and separation 
of the divided tissues, and to retain the head of the femur in its place; 
finally, in the gradual execution of movements proper to complete the 
coaptation of the surfaces, and to establish, little by little, the physio- 
logical movements of the joint. 

Other surgeons have confined their efforts to the reduction of the 
dislocation, and they have, consequently, abandoned all those cases in 
which, owing to the complete absence of the natural socket, or to the 
want of sufficient mobility in the limb, the reduction was deemed 
impossible ; but Guerin has gone a step farther, and has sought to es- 
tablish a new socket upon some point of the pelvic bones as near as 
possible to its natural articular fossa. " The means which I adopt," 
says Guerin, " are based upon a recognition of the processes which 
nature employs for the attainment of the same purpose, and of which 
mine are but an imitation. I have shown that the essential condition 
of the formation of artificial cavities is perforation of the articular 
capsule, and the placing in contact of the luxated extremity with an 
osseous surface, and that the condition of the maintenance of this ab- 
normal rapport is the intimate adherence of the borders of the rent 
with the circumference of the new cavity. Now it appeared to me 
that art could realize, in all points, the conditions which preside at 
the spontaneous formation of artificial joints. To this end I commence 
by practising under the skin, and at the point corresponding to that 
where it is most convenient to fix the luxated extremity, scarifications 
of the capsule, down to the bone to which it is attached. By this 
means the dislocated extremity is placed in immediate contact with 
the bony surface upon which it reposes. It makes upon this point a 
beginning of the work of organization resulting from the adhesion 
and fusion of the scarified points with the corresponding points of 
this surface. Then, in order to circumscribe and imprison the lux- 
ated extremity, in this place of election, I practise all about deep scari- 
fications, which tend to excite the same work of organization and to 

1 Dupuytren, op. cit., pp. 176-8. 



706 CONGENITAL DISLOCATIONS. 

establish fibro-cellular adhesions between the incised borders of the 
capsule and the contiguous bony surfaces. 

"Finally, when the fibro-cellular adhesions are supposed to be suf- 
ficiently solid to resist the movements of the new articulation, I pro- 
voke, little by little, the development of the cavity destined to embrace 
the luxated extremity by the means which nature herself employs in 
analogous circumstances; that is to say, by circumscribed and fre- 
quent movements of this articulation." 1 

The treatment ought to be commenced as early as possible, no ex- 
amples of success having been recorded in persons over fifteen years 
of age ; while the youngest child whose treatment is reported as suc- 
cessful was three years of age. 

For the purpose of making the requisite extension, and of main- 
taining the bone in place, Pravaz (who does not, however, adopt 
Guerin's practice of establishing for the head of the bone a new 
socket but only seeks to reduce and maintain it in its old socket) has 
invented several forms of apparatus adapted to the different stages of 
progress in the treatment. Heine, of Cannstadt, Gruerin, and others have 
also suggested special contrivances for the same purpose ; but no sur- 
geon who understands fully the principle upon which the cure is sup- 
posed to be accomplished, will be at a loss for apparatus suitable for 
making the necessary extension, or for maintaining the reduction 
when once it has been effected. 

The length of time required for the completion of a cure, where a 
cure is possible, must vary according to the age and health of the 
patient, and according to the pathological condition of the joint, and 
may be found to extend from a few months to one or more years. It 
is unnecessary to say that where the accomplishment of the cure de- 
mands a period of several years, the treatment must be intermittent 
and greatly varied, so as to suit all the changing circumstances in the 
condition of the patient. 

Finally, if after a fair trial we fail to accomplish a cure, or if the 
condition of the child will not warrant even the attempt, we ought as 
far as possible to seek to prevent an increase of the deformity, by 
such means as our ingenuity may suggest, or by such judicious appli- 
ances and general management as we have seen recommended by 
Dupuytren. 

South says that he has seen one case of double dislocation in which 
the walking was at first extremely difficult, but from the fifteenth 
year and onwards the patient so improved, that at the twentieth year 
scarcely any trace of the peculiar gait could be discovered. 2 

§ 14. Congenital Dislocations of the Patella. 

Palletta found a dislocation of the patella in the cadaver of a young 
man ; which he supposed to be congenital. 3 Michaelis has reported 

1 Guerin, op. cit., pp. 81-3. 

2 South, Note to Chelius, op. cit., vol. ii. p. 245. 

3 Palletta, Exercitationes Pathologies, p. 91. 



CONGENITAL DISLOCATIONS OF THE KNEE. 767 

two cases ; one in a young man of seventeen years, and the other in 
a girl of fourteen, each of whom affirmed that it had existed from 
birth. 1 Both of these examples presented themselves at the hospital 
on account of hydrarthrosis of the knee-joints, and Malgaigne, who 
had himself seen a similar case, is disposed to regard them all as 
examples of pathological rather than congenital luxations.. Periat 
reports a case in which the dislocation was only produced by walk- 
ing, and in relation to the authenticity or pertinence of which Mal- 
gaigne seems also to entertain a doubt. 2 

South says that he has seen a congenital dislocation on both legs, 
in an aged man. The patellae rested entirely upon the outer faces of 
the external condyles, leaving the front of the knee-joint completely 
uncovered. When the limbs were extended the patellas could be 
easily made to resume their natural positions, but on the patient's 
making the slightest movement they were again displaced. The 
knees were very much inclined inwards, the feet outwards, and his 
gait was difficult and unsteady. 3 

The most remarkable example, however, has been reported by Dr. 
E. J. Caswell, of Providence, K. I., inasmuch as no less than five 
members of the same family have double congenital dislocations of 
the patellar The man who was the subject of Dr. Caswell's special 
examination is 43 years old, and possessed of a good constitution. 
The patella lay upon the outer condyles, and are movable, performing 
their functions nearly as well as if placed in their proper positions. 
He walks without difficulty upon level ground, or upon an ascending 
plane, but great caution is required in descending. The right patella 
is longer and less movable than the left, and the muscles of both of 
his lower extremities are small. " In addition to his labor as an 
operative, he cultivates a small farm." Dr. Caswell examined his 
son and found the same malposition, but less marked than in the case 
of the father. The father then stated that his own father, his sister, 
and the son of his half brother by the same father, had a similar de- 
formity. 4 

§ 1 5. Congenital Dislocations of the Knee. 

The head of the tibia has been found, at birth, dislocated forwards, 
backwards, inwards, outwards, inwards and backwards, outwards and 
backwards, and simply rotated inwards. 

Most of these luxations were incomplete ; and of them all, the dis- 
location forwards has been observed much the most often. 

A subluxation forwards of the head of the tibia has been seen by 
Guerin in a foetal monster, accompanied with extreme retraction of 
the extensor muscles of the leg. 5 Cruveilhier has dissected a foetus 
affected with a similar subluxation. 6 

1 Michaelis, Rev. Med.-Chirurg., torn. xv. p. 56. 

2 Periat, Malgaigne, op. cit., torn. ii. p. 932. 

3 South, Note to Chelius, op. cit., vol. ii. p. 247. 

4 Caswell, Amer. Journ. Med. Sci., July, 1865. 

5 Guerin, op. cit., p. 33. 

6 Cruveilhier, Atlas de l'Anat. Patholog., 2e livr., pi. 2. 



763 CONGENITAL DISLOCATIONS. 

In these examples the displacement forwards at the articular surface 
was but slight, and the anterior flexion of the limb inconsiderable ; 
but when the dislocation is complete, or nearly so, the deformity is 
in all respects very much increased ; as the following examples will 
illustrate : — 

Dr. D. H. Bard, of Troy, Vermont, has reported an example of 
complete anterior luxation of the tibia, seen by himself, in a new-born 
infant. The leg was found drawn forwards upon the thigh at an acute 
angle, so that the toes pointed toward the face of the child, and the 
bottom of the foot was directed forwards. By the application of 
moderate force, the limb could be straightened and even flexed com- 
pletely. These motions inflicted no pain. It was especially noticed 
that in bringing down the leg from its position of extreme anterior 
flexion (extension) more force was required in the first part of the 
manoeuvre than in the last ; and that if, having brought the leg down, 
it was left to itself, it immediately resumed the abnormal position, 
moving at first slowly, but after a time much more rapidly. 

The limb was confined by bandages for a short time, and it did not 
afterwards show any disposition to return to its unnatural position. 
The child did well, and when it began to use its legs, no difference 
could be discovered between them. 1 

J. Youmans, of Portageville, X. Y., reports a similar case which 
occurred in his own practice. A healthy woman was delivered on the 
16th of Aug. 1859, of a full grown female child, whose left knee was 
so completely dislocated that the toes rested upon the anterior part of 
the thigh near the groin. Dr. Youmans immediately took hold of 
the limb and brought it to its natural form, but as soon as he relin- 
quished his hold, it flew back to its original position. Having again 
straightened the leg it was retained in place easily by two pieces of 
whalebone tied upon each side of the thigh and body. Some soreness 
and swelling ensued, and it was some weeks before the splint could 
be safely removed. At the time of the report, Oct. 11, 1860, the child 
was using the limb with as much freedom and dexterity as other 
children of her own age. 

In the report particular attention is called to the disposition on the 
part of the limb to resume its unnatural position with a spring, show- 
ing contraction of the anterior muscles of the thigh : to the fact that 
the patella of this knee was smaller than the other, and that the skin 
on the front of the knee was wrinkled as it is usually back of the 
knee in fat children. 2 

I have mentioned a case of congenital forward dislocation of both 
tibiae which came under my observation, in the section on congenital 
dislocations of the hip, and I have recently seen a case of congenital 
subluxation of both tibiae backwards, occasioned by contraction of the 
hamstrings. Section of the muscles restored the bones nearly to their 
normal positions. 

1 Bard, Amer. Journ. Med. Sci., Feb. 1835,p. 555, from Bost. Med. and Surg. Journ. 
Nov. 26, 1S34. 

2 Youmans, Bost. Med. and Surg. Journ., Oct. 25, 1S60, vol. 63, p. 250. 



CONGENITAL DISLOCATIONS OF THE KNEE. 769 

Chatelain was consulted in relation to a similar case, in which the 
restoration of the limb to its natural position was also easily effected, 
and by means of three metallic splints, applied during about fifteen 
days, the cure was consummated. Chatelain directed, however, that 
the leg should be kept flexed upon the thigh eight days longer. 1 

Kleeberg found a child with the leg so much flexed forwards (ex- 
tended) upon the thigh that the popliteal region became the lowest 
point of the limb ; in front and above the articular extremity of the 
tibia could be felt, and the condyles of the femur made a correspond- 
ing projection behind into the popliteal space. This was plainly an 
example of complete luxation ; and, contrary to what was observed 
in Bard's case, flexion of the limb backwards was difficult and painfui. 

The treatment was commenced by securing the limb in a straight 
position by means of a splint and roller ; subsequently, Kleeberg car- 
ried the limb back to an obtuse angle, and finally, it was kept eight 
days in a position of extreme flexion. A complete cure was sai,d to 
have been accomplished in about two weeks. 2 

Gruerin has seen a subluxation backwards, accompanied with a slight 
rotation of the head of the tibia outwards, in a girl fourteen years old ; 
and which, he affirms,' was congenital, characterized by a permanent 
flexion (backwards) of the leg upon the thigh, and a sliding of the 
condyles of the tibia backwards. 

This girl was under Guerin's treatment, but with what result is not 
stated. 3 

Chaussier found both tibiae displaced backwards in an infant other- 
wise deformed. 4 

Eobert speaks of an example of lateral subluxation in a man, which 
had existed from birth. The right knee was thrown inwards, and the 
left outwards. 5 

Gruerin " operated" publicly upon a child, two years old, who had a 
congenital dislocation of the head of the tibia backwards and inwards, 
accompanied with a slight rotation of the leg inwards. 6 In what man- 
ner he operated, and with what result, he does not inform us. 

The same writer speaks of a subluxation backwards and outwards, 
with rotation in the same direction, a deformity which, he affirms, is 
very frequent, and which appears especially after birth, although the 
causes which produce it have given their first impulse during intra- 
uterine life. 

The case quoted from Eobert, by Malgaigne, as an example of dis- 
location inwards, seems to have been rather a case of semi-rotation 
of the articular surfaces, the inner condyle being thrown back into 
the popliteal space, while the outer condyle still retained its natural 
position. 

1 Chatelain, Bibliotheque Med., torn. lxxv. p. 85. 

2 Kleeburg, Malgaigne, op. cit., p. 983. 5 Robert, Malg., op. cit., p. 985. 

3 Guerin, sur les Lux. Congen., p. 33. 6 Gruerin, sur les Lux. Congen., p. 33. 

4 Chaussier, Malgaigne, op. cit., p. 884. 



770 CONGENITAL DISLOCATIONS. 



§ 16. Congenital Dislocations of the Tarsal Bones. 

Under this general term may be included all those varieties of sub- 
luxation of the several bones which compose the tarsus, and which are 
known as examples of talipes or club-foot ; such as tibio-astragaloid 
luxations, astragalo-scaphoid, calcaneo-astragaloid, calcaneo-cuboid, &c. 

Although these deformities may properly enough claim a place in 
a chapter on congenital dislocations, they have so long been the sub- 
jects of special treatises as to justify their exclusion from the present 
volume. 



§ IT. Congenital Dislocations of the Toes. 

Observed occasionally at the metatarso-phalangeal articulations ; the 
articular facets of the first phalanges suffering a subluxation upwards, 
or laterally upon the corresponding metatarsal bones. 

Gruerin has noticed especially a congenital lateral subluxation of 
the great toe. 1 

1 Guerin, op. cit., p. 34. 



INDEX. 



PAKT I.— FRACTURES. 



Abscess in fracture of the sternum, 169 
Acetabulum, 339 
Acromion process, 206 
Amesbury's thigh, splint, 407 
Anatomical neck of humerus, 313 
Anaplasty in fractures of the septum narium, 

Anchylosis after Colles's fracture, 278 
after fractures of elbow, 253 * 
excision for anchylosis of knee, 452 

Apparatus immobile, 54 

in fractures of the leg, 474 

Arytenoid cartilages, fractures of, 135 

Ashhurst, fracture of astragalus, 483 

Astragalus, 480 

Atlas, 163 

and axis, 164 

Axis, 161 

Ayres, compound fracture of clavicle, 186 

Badly united fracture of leg, 479 
Bartlett's apparatus for broken clavicle, 195 
Barton's bran dressing, 61, 478 

bandage for fractured jaw, 130 

trephining vertebrae, 149 

fracture of lower end of radius, 277 

fracture-bed, 430 
Base of acetabulum, 339 
Bauer's wire splints, 476 
Beans, lower jaw, 125 
Bending of bones, 72 
Bigelow, fracture of axis, 161 

stellate fracture of lower end of radius, 
275 
Boardman, fracture of zygoma, 107 

perineal band, 414 
Body of the scapula, 200 
Bodies of the vertebrae, 152 
Bond's elbow splint, 248 

radius splint, 280 
Box for leg, 476 
Boyer's thigh splint, 407 
Brainard, perforator, 69 
Buck, lower jaw, 120 

thigh splint, 415 
Burges's thigh apparatus, 411 

Calcanbum, 485 

Carpal bones, 323 

Cartilages, 176 

Carved splints, radius, 287 

Cervical ligaments, strains of, 158 



Cervical vertebras, bodies of five lower, 156 

axis, 161 

atlas, 163 

atlas and axis, 164 
Chapin's thigh apparatus, 417 
Children, fracture of femur, 402, 414, 420 

422 
Chronic rheumatic arthritis, 374 
Clark's case of fracture of pelvis, 332 
Clavicle, 177 

partial fractures, 178 

repair of fractures, 185 
Cline, trephining vertebras, 149 

fracture of atlas, 163 
Coates, fracture bed, 430 

bran dressings, 61 
Coccyx, 347 

Colby, neck of femur within capsule, 371 
Colles's fractures, examples, 271 
Common signs of fracture, 33 
Compress, pasteboard, for fractured jaw, 127 
Compound fractures, 60 

forearm, 314 

thigh, Gilbert on, 423 

patella, 447 

tibia and fibula, 462 
Concussion of spinal marrow, 158 
Condyles of humerus, 252 
internal, 258 
external, 260 
base, 242 
base and between condyles, 250 

of femur, 437 

external, 437 
internal, 438 
base, 394 

between condyles, 440 
Congenital, 31, 233, 453 

Cooper, Sir Astley, fracture of olecranon pro- 
cess, 309 

neck of femur within capsule, 349 

patella, 451 
Coracoicl process, 209 
Coronoid process of ulna, 297 
Cotyloid cavity, 339 

Counter-extension by adhesive plaster, 415 
Cradle for leg, 477 

Crandall, extension, fracture of leg, 473 
Cricoid cartilage, 141 
Crosby, neck of femur within capsule, 371 

external condyle, 437 



772 



INDEX — FRACTURES. 



Dalton, John C, fracture of neck of femur, 

360 
Daniels' fracture-bed, 431 
Deformities of legs, 479 
Delayed or non-union, 61 

humerus, 234 
Dextrine, 55 
Diagnosis, general, 33 
Dieffenbach, tenotomy in fracture of olecranon 

process, 313 
Dislocation of humerus, differential diagnosis, 

226 
Division of fractures, general, 27 
Dorsal vertebrae, 155 
Dorsey, fracture of patella, 450 
Dudley, treatment of fractures by bandages, 

419 
Dugas, sign of dislocation of humerus, 226 

thigh apparatus, 415 
Dupuytren's case of fracture of a dorsal ver- 
tebra, 155 

body of a lower cervical vertebra, 156 

dressing for fracture of fibula, 460 

Elbow splint, Physick's 246 

Kirkbride's, 247 

Rose's, 247 

Welch's, 247 

Bond's, 248 

the author's 249 
Ellis, fracture of lower jaw, 111 
Else, fracture of axis, 161 
Emphysema in fracture of ribs, 174, 175, 176 
Endless screw for extension of thigh, 428 
Epicondyle of humerus, external, 257 

internal, 253 
Epiphyseal separations, 28 

acromion, 207 

humerus, upper end, 221 
lower end, 242 

femur, upper end, 352 

lower end, 383, 428, 441 

trochanter major, 391 
Epiphyses, sternum, 166 

scapula, 208 

humerus, 220 

radius, 292 

ulna, 301 

os innominatum, 331 

femur, 347 

tibia, 453 

fibula, 457 
Epitrochlea, 252 
Etiology, general, 29 
Eve, non-union of ribs, 173 

patella, 444 
Exciting causes, general, 29 
Experiments on bending, 72 

on partial fractures, 79, 82 
External epicondyle of humerus, 257 

condyle of humerus, 260 
femur, 437 
Extension of thigh by adhesive plaster, 422 

Fauger, Colles's fracture, 282 
Felt splints, 51 
Femur, 347 

neck, within capsule, 349 

neck, anatomy of, George K. Smith, 373 

differential diagnosis, 386 

without capsule, 383 

trochanter major and base of neck, 390 



Femur — 

epiphysis of trochanter major, 391 

shaft, 393 

external condyle, 437 

internal condyle, 438 

between condyles, 440 

base of condyles, 394 
Fibula, 457 
Fingers, 327 
Fissures, 85 

neck of femur, 351 
Flagg's thigh apparatus, 414 
Floating cartilages, in knee-joint, 700 
Forearm, 314 

Fore's case of fracture of hyoid bone, 135 
Four-tailed bandage for broken jaw, 131 
Fracture beds, 431 

Jenks, 431 

Hewson, 430 

Barton, 430 

Coates, 430 

Daniels, 432 

Burges, 411, 430 

Crosby, 432 
Fracture-box, 478 

Gangrene, after fracture at base of condyles 
of humerus, 246 

Dupuytren's cases after fracture of radius, 
288 

Robert Smith's cases, 289 

Norris, 291 

after fracture of forearm, 317 

leg, from tight roller, 419 

patella, 450 

from tight bandages, 456 

leg from tight bandages, 469 

from use of "apparatus immobile," 475 
Gibson, bandage for fractured jaw, 130 

fracture of clavicle, 187 

of coracoid process, 210 
Gilbert, apparatus for broken femur, 423 

leg, 472 
Glenoid cavity of scapula, comminuted, 205 
Granger, fracture of epicondyle, 253 
Greater tubercle of humerus, 227, 230 
Gunning's interdental splint, 125 
Gunshot fractures, 487 

treatment in, 490 
Gutta-percha splints, 52 

Harris, separation of upper maxillary bones, 

102 
Harrold, lumbar vertebra?, 155 
Hartshorne, thigh apparatus, 416 
Hays, radial splint, 281 
Hay ward, lower-jaw, 122 
Head of femur, 349 

of radius, 266 

and anatomical neck of humerus, 213 

and neck of humerus, longitudinal frac- 
ture, 218 
Hewson, fracture-bed, 430 
Hodge, thigh-splint, 424 
Hodgen's fracture cradle, 491 

" wire, suspension splint, 477 
Horner, thigh apparatus, 416 
Humerus, 212 

anatomical neck, 213 

head and neck, 213, 

tubercles, 217 

longitudinal fracture of head and neck, 218 



INDEX — FRACTURES. 



773 



Humerus — 

surgical neck, 220 

upper epiphysis, 221 

differential diagnosis, 226 

shaft, 232 

lower epiphysis, 242 

base of condyles, 242 

with splitting of condyles, 250 

condyles, 252 

internal epicondyle, 253 

external epicondyle, 257 

internal condyle, 258 

external condyle, 260 

delayed union, 263 

dislocation of, 226 
Hutchinson, leg splint, 471 
Hutchinson, J. C, fracture of spine, 150 
Hyoid bone, 134 

Ilium, 336 

Immovable apparatus, 54 

leg, 475 
Impacted fractures, 28 

head and neck of humerus, 213 

tubercles, 217 

neck of femur within capsule, 349 
without the capsule, 383 
Incomplete fractures, 72 
Inferior maxilla, 109 

Interstitial absorption of neck of femur, 374 
Intra-uterine fracture, 30, 233, 453 

fracture of tibia, 453 
Internal condyle of humerus, 258 

femur, 438 
Interdental splints, 123 
Ischium, 334 

Jackson, acromion process, 207 
Jarvis's adjuster, 471 
Jenks, fracture-bed, 430 
Johnson, neck of femur, 359, 364 

Key, lumbar vertebrae, 155 
Kimball, fracture of femur, 415 
Kirkbride, elbow splint, 247 

Larynx, fracture of, 139, 141 

Lente, fracture of dorsal vertebra, 155 

femur, 424 

non-union, 67 

pelvis, 331 
Lewitt, patella, 447 
Liston, thigh splint, 404 

leg splint, 475 
Lockwood, fracture of humerus at birth, 233 
Long splints, 48 
Lonsdale, extension in fracture ofhumerus,236 

patella, 451 
Lower jaw, 109 

Malar bone, 98 

McDowell, remarkable displacement of head 
of humerus, 214 

separation of upper epiphysis, 221 
Malgaigne, apparatus for fracture of leg, 478 
Many-tailed bandage, 47 
March, acromial separations, 207 

neck of femur, 367 
Maxilla, superior, 101 

inferior, 109 
Metacarpus, 324 
Metatarsus, 485 



Metallic splints, 48 

Monahan, fracture of astragalus, 481 

Morbus coxae senilis, 374 

Morland, statistics of fracture of tibia and 

fibula, 463 
Mott, prognosis in Colles's fracture, 279 

fracture of femur, 408 

electricity in non-union, 67 
Mussey, fracture of coracoid process, 210 

neck of femur, 363 
Mutter's "clamp," 125 

neck of radius, 265 

Neck of femur, 348 

within capsule, 349 

prognosis, 355 

G. K. Smith on, 373 

without capsule, 383 
Neck of humerus, anatomical, 213 

surgical neck, 220 
Neck of lower jaw, 113 
Neck of radius, 265 
Neck of scapula, 205 

signs of fracture, 227 
Neill, maxilla superior, 105 

coracoid process, 209 

fracture of patella, 449 
thigh, 412 

leg, simple fracture, 471 
compound fracture, 472 
Nelaton, radial splint, 281 
Non-union, 61 

humerus, 237 

lower jaw, 118 

ribs, 173 
Norris, delayed and non-union, 62 

astragalus, 484 

gangrene from bandages, 291 

tibia, 456 
Nose, fracture of, 90 
Nott, wire splints, 48 

thigh apparatus, 409 

Odontoid process of axis, 161 
Olecranon process, 306 

tenotomy, 313 
Ossa nasi, 90 

Partial fracture, 76 

Patella, 442 

Pelvis, 330 

Phalanges of fingers, 327 

toes, 487 
Pubes, 331 

Radius, 264 
Radius and ulna, 314 

Reduction of fractures : general considera- 
tions, 44 
Refracture of badly-united legs, 479 
Repair of fracture, 37 
Resection for badly-united fractures, 479 
Ribs, 171 

cartilages of, 171 
Rim of acetablum, 342 
Rodet, neck of femur, 350 
Rogers, trephining vertebrae, 150 
Roller, 46 
Rose, elbow splint, 247 



Sacrum, 345 
Sacro-iliac symphysis 



345 



74 



IXDEX — FRACTURES 



Salter's cradle for leg, 477 

Sargent, separation of upper maxillary bones, 

101 
Scapula, 200 

body, 200 

neck, 198, 205 

acromion process, 206 

coracoid process, 209 

epiphyses of, '207 
Scultetus, bandage, 46 
Semeiology, general, 33 
Septum narium, 94 
Setting bones, 44 
Seutin, dressing, 54 

anaplasty, 97 
Shaft of humerus, 232 

radius, 269 

ulna, 293 

femur, 393 
Shoulder-joint; differential diagnosis of acci- 
dents, 226 
Shrady, radius splint, 282 

thigh splint, 416 
Side splints, 48 
Sling for broken jaw, 131 
Smith, E. P., radial splint, 282 
Smith, H. H., fracture of neck of femur, 364 
Smith, Nathan R., fracture of femur, 408 
Smith, Robert, head of humerus, 214 
Smith, Stephen, fracture of lower jaw, 118 
Smith, Geo. K., insertion of capsule of hip- 
joint, Ac, 386 
Spencer, fracture of humerus at base of con- 
dyles, 252 
Spinal marrow, concussion, 158 
Spinous processes: vertebrae, 142 

ilium, 336, 337 
Splints, 48 
Starch bandage, 53 

leg, 474 
Sternum, 165 

Stone, base of condyles and resection, 252 
Styloid process of radius, 276 
Surgical neck of humerus, 220, 228, 230 
Swan, neck of femur within capsule, 358 
Swing box for leg, 477 
Symphyses of pelvis, 330 

pubes, 330 

sacro-iliac, 346 
Symphysis pubis, separation of, 331 

Tarsus, 480 

astragalus, 480 

calcaneum. 481 
Tenotomy in fractures of olecranon process, 
313 



Thompson, fracture of lumbar vertebrae, 49 

Thyroid cartilage, 139 

Thyroid and cricoid cartilages, 139 

Tibia. 453 

Tibia and fibula, 461 

Toes, 487 

Transverse processes of spine, 145 

Treatment of fractures, general, 44 

Trephining for fracture of vertebrae, 149 

Trochanter major, 390 

Trochlea of humerus, 258 

Tubercles of humerus, 218, 228, 230 

Ulna, resection of, 292 
Ulna, 293 

shaft, 293 

coronoid process, 297 

olecranon process, 306 
Upper epiphysis, humerus, 229 

femur, 352 
Upper maxillary bones, 101 

Van Btjren, W. H., fracture of humerus. 232 
Vanderveer, fracture in utero, 33 
Vandeventer, fracture of vertebral arch, 147 
Velpeau, mode of dressing fractures with dex- 
trine and rollers, 55 
Vertebral arches, 146 
Vertebrae, 142 

spinous processes, 142 
transverse processes, 145 
vertebral arches, 146 
bodies, 152 

lumbar, 153 
dorsal, 155 
cervical, 156 
axis, 161 
atlas, 163 
atlas and axis, 164 

Warren on anchylosis at elbow-joint, 263 
Waters, compound fracture of humerus, 232 
Watson, fracture of lower jaw, 112 

lower epiphysis of humerus, 242 

patella, 446 
Weber, plaster of Paris bandage, 58 
Wells, internal condyle of femur, 438 
Whittaker, pelvis, 335 
Wire splints, 48 

Wire rack for fracture of leg, 478 
Wood, fracture of patella, 450 
Wooden splints, 49 
Wrist, 323 

Zygomatic arch, 106 



INDEX — DISLOCATIONS, 



775 



PART II.— DISLOCATIONS. 



Ancient luxations, 508 

inferior axilla, 508 

spine, 516 

clavicle, outer end, 536 

humerus, 562 

head of radius forwards, 584 

radius and ulna backwards, 594 

thumb, 619 

femur, 678 
Andrews, inferior maxilla, 506 
Ankle-joint, 702 

Annan, dislocation of femur, 664 
Anomalous dislocations of the hip, 673. See 

Femur. 
Atlas, dislocations of, 525 
Ayres, dislocation of cervical vertebra, 521 

Batcheldek, head of radius, 582, 587 

thumb, 626 
Bard, H. H. Congen, dislocation of tibia, 737 
Biceps, rupture or displacement of, 580 
Blackman, ancient dislocations of humerus, 
566 

femur, reduced after six months, 678 
Bloxham's dislocation tourniquet, 650 
Brainard, reduction of ancient luxation of 
elbow, 599 

reduction of femur by a novel method, 669 

Canton, radius and ulna forwards, 608 
Carpus, 609 

backwards, 611 

forwards, 614 

congenital, 759 
Carpal bones among themselves, 617 
Carpo-metacarpal articulation, 619 
Cartilages, of ribs from one another, 528 

in knee-joint, 700 
Caswell, dislocation of patella, 767 
Clavicle, dislocations of, 529 

sternal end forwards, 529 

sternal end upwards, 533 

sternal end backwards, 534 

acromial end upwards, 536 

acromial end downwards, 541 

under coracoid process, 542 

congenital, 754 
Clove hitch, 504 
Compound pulleys, 504 
Compound dislocations of the long bones, 731 

reduction in, 737 

non-reduction in, 739 

amputation in, 740 

tenotomy in, 741 

resection in, 741 
Congenital dislocations ; general observations 
and history, 746 

general etiology, 748 

inferior maxilla, 749 

spine, 752 

pelvic bones, 753 

sternum, 753 



Congenital Dislocations — 

clavicle, 754 

shoulder, 754 

radius and ulna backwards, 758 

head of radius, 758 

wrist, 759 

fingers, 760 

hip, 760 

patella, 766 

knee, 767 

tarsus, 770 

toes, 770 
Cooper, Sir Astley, method of reducing dislo- 
cation of humerus, 562 
Coxo-femoral dislocations, 634. See Femur. 
Crosby, dislocation of thumb, 626 

ancient dislocation of elbow, 600 

Damainville, statistics of dislocations of fe- 
mur, 651 
Direct causes of dislocations, 499 
Dislocations, 496 

Division and nomenclature of dislocations, 496 
Double dislocation of lower jaw, 505 
Dupierris, femur reduced after six months, 679 
Dynamometer, 651 

Elbow-joint, 591 

Exciting causes, general, 499 

Extension by a twisted rope, 504 

Femur, dislocation of, 634 

dislocation on dorsum ilii, 636 

reduction by manipulation, 641 
reduction by extension, 647 
dislocation into great ischiatic notch, 659 
dislocation into foramen thyroideum, 665 
dislocation upon the pubes, 669 
anomalous dislocations of the femur, 673 
downwards and backwards upon the 

body of the ischium, 674 
downwards and backwards into lesser 

ischiatic notch, 675 
behind tbe tuber ischii, 675 
directly up, 673 
directly down, 676 
forwards into perineum, 677 
ancient dislocations, 678 
partial dislocations, 681 
with fracture, 682 
in children, 634 
congenital, 760 
Fenner, dislocation of femur on dorsum ilii, 637 
Fibula, upper end forwards, 713 
backwards, 714 
lower end, 715 
"Fifth" dislocation of femur, 675 
Fingers, dislocations of first phalanx, 621, 630 
second and third, 631 
congenital, 770 
Foot, dislocation outwards, 702. See Tibia. 
Fountain, dislocation of femur upon pubes, 672 



INDEX — DISLOCATIONS. 



Gazzam, rotation of patella on its inner mar- 
gin, 691 
General division, 497 
General direct or exciting causes, 499 
General predisposing causes, 498 
General prognosis, 502 
General pathology, 501 
General treatment, 502 
General symptoms, 499 

Gibson, ancient dislocation of humerus, 568 
Gilbert, A. W., dislocation of lower jaw, 506 
Grant, astragalus, 721 

Graves, dislocation of dorsal vertebrae, 515 
Gunn, dislocation of thigh on dorsum ilii, 638 

Hart, dislocation of astragalus, 719 
Hartshorne, reduction of humerus by mani- 
pulation (note), 570 
Head upon the atlas, 525 
Hinckerman, cervical vertebrae, 520 
Hodder, dislocation of femur, 652 
Hodge, statistics of dislocations of the femur, 

653 
Horner, partial dislocation of fourth cervical 

vertebra, 518 
Howe, reduction of dislocation of the hip by 

manipulation, 644 
Humerus, dislocations of, 543 
downwards, 544 
forwards, 570 
backwards, 575 
partial. 579 
ancient, 562 
with fracture, 568 
congenital, 754 
Humero-scapular dislocation, 543. See Hu- 
merus. 
Hutchinson, dislocation of femur, 634 

Ilio-ptjbic dislocation of femur, 669 
Indian "puzzle," 628 
Inferior maxilla, 505 

double dislocation, 505 

single dislocation. 509 

congenital dislocation, 749 
Ingalls, reduction of dislocation of hip by 

manipulation, 646 
Internal derangement of knee-joint, 700 
Ischio-pubic dislocation of femur, 665 
Ischiatic dislocation of femur, 659 

Jarvis's adjuster, 504, 565, 649 

Kirkbride, dislocation of the femur upon 

posterior part of the body of the ischium, 

675 
Knee, slipping of semilunar cartilages, 700. 

See Tibia. 
Krackowitzer, dislocation of head of radius in 

delivery, 582 

La Mothe, method of reducing dislocation of 

humerus, 558 
Lehman, spontaneous dislocation of shoulder, 

545 
Lente, fifth cervical vertebra, with fracture, 518 
fifth cervical vertebra, without fracture, 

518 
femur directly upwards, 673 
Levis, reduction of dislocation of thumb, 627 
Ligamentum patellae, rupture of, 691 
Long bones, compound dislocation in, 731 



Lower jaw, 505 
Lumbar vertebrae, 513 

Markoe, on reduction of dislocation of femur, 
638, 647 
head of radius backwards, 587 
femur with fracture, reduced, 684 

Maxson, dislocation of cervical vertebrae, 521 

May, reduction of old dislocation of humerus, 
562 

Mercer, on partial dislocations of humerus, 581 

Metacarpus, 619 

Metacarpo-phalangeal articulation, 621 

Metatarsus, 727 

Moore, on reduction of dislocation of femur, 
638 

Mussey, dislocation of thumb, 626 
ancient dislocation of elbow, 600 

Norris, ancient dislocations of the humerus, 

568, 573 
dislocation of humerus mistaken for a 

contusion, 573 
compound dislocation of thumb, 628 

Occipito-atloidean dislocations, 525 

Parker, head of humerus in sub -scapular 
fossa, 571 

backwards, 576 

head of radius backwards, 588 

head of radius outwards, 589 

femur into perineum, 677 
Patella, outwards, 686 

inwards, 689 

on its axis, 689 

upwards, 691 

downwards, 692 

congenital, 766 
Pathology, general, 501 
Pelvis, traumatic separations, 330. (Part I.) 

congenital, 753 
Phalanges, thumb and fingers, 621 

toes, 730, 770 
Pope, dislocation of femur into perineum, 678 
Predisposing causes, general, 498 
Prognosis, general, 502 
Pseudo-luxations of inferior maxilla, 510 
Pulleys, 504 
Purple, dislocation of cervical vertebrae, 519 

Radius, head dislocated forwards, 582 

backwards, 590 

outwards, 591 

outwards and backwards, 601 

inwards, 605 

inwards and upwards, 605 

congenital, 758 
Radius and ulna, dislocation backwards, 591 

congenital, 758 

outwards, 601 

inwards, 605 

forwards, 608 
Radio-carpal articulation, 609. See Carpus. 
Radio-ulnar articulation, inferior, 615 
Rupture of quadriceps femoris, 692 
Reid, reduction of dislocation of femur by 

manipulation, 646 
Ribs from vertebrae, 526 

from sternum, 527 

one cartilage upon another, 528 



INDEX — DISLOCATIONS. 



t I i 



Rochester, sternal end of clavicle upwards, 533 
Rudiger, dislocation of dorsal vertebrae, 516 

Sacro-sciatic dislocation of femur, 659 
Sanson, third cervical vertebra, 519 
Schuck, dislocation of cervical vertebra, 520 
Sessamoid bones, dislocation of, 701 
Shoulder, dislocation of, 543. See Humerus. 
Single dislocation of lower jaw, 505 
" Sixth" dislocation of femur, 673 
Skey, method of reducing dislocation of hu- 
merus, 561 
Smith, Nathan, on reduction of dislocation of 
the humerus, 558 
reduction of femur by manipulation, 643 
Smith, Nathan R., on reduction of humerus, I 

558 
Smith, H. H., on reduction of humerus, 562 
Spencer, dislocation of cervical vertebra, 519 



>pme, 



512. 



Vertebn 



Spontaneous dislocation of femur, 731 
Squire, T. H., dislocation of radius and ulna 

inwards, 606 
Sternum, diastasis, 161. (Part I.) 

congenital dislocations, 753 
Subcoracoid dislocation of humerus, 570 
Subclavicular dislocation of humerus, 570 
Subcotyloid dislocations of femur, 676 
Subluxation of the jaw, 510 
Subglenoid dislocation of the humerus, 544 
Subpubic dislocation of femur, 665 
Subspinous dislocation of humerus, 575 
Swan, dislocation of dorsal vertebra, 516 
Symptomatology, general, 499 

Tarsus, 715 

astragalus, 715 

astragalo-calcaneo-seaphoid, 722 

calcaneum, 724 

middle tarsal dislocation, 724 

os cuboides, 725 

os scaphoides, 725 

cuneiform bones, 726 

congenital, 770 
Tendons, dislocation of, 739, 752 
Thigh, 634. See Femur. 
Thumb, first phalanx, 621 
backwards, 621 
forwards, 629 



Thumb- 
second phalanx, 631 
Tibia, dislocation of upper end, 692 

backwards, 693 

forwards, 695 

outwards, 697 

inwards, 698 

backwards and outwards, 699 

congenital, 767 
lower end, inwards, 702 

outwards, 707 

forwards, 708 

backwards, 712 
Tibia, dislocation of lower end, 702 
Tibio-tarsal luxations, 702 
Toes, 730 

congenital, 770 
Treatment, general, 502 

Trowbridge, head of humerus backwards, 576 
Twisted rope, extension, 504 

Ulna, upper end backwards, 590 
lower end backwards, 615 
forwards, 616 
Unilateral luxation of lower jaw, 509 

Van Buren, W. H., dislocation of humerus 
"backwards, 576 

reduction of femur by manipulation, 654, 
667 
Vertebras, 512 

lumbar, 513 

dorsal, 514 

six lower cervical, 517 

atlas upon axis, 524 

head upon atlas, 525 

congenital dislocations, 752 
Voluntary dislocations, 685 

Warren, humerus with fracture, 568 

Watson, dislocation of patella outwards, 691 

Wells, dislocation of tibia, 700 

Windlass for extension, 504 

Wood, dislocation of cervical vertebrae, 521 

humerus, with fracture, 571 
Wrist, 609. See Carpzcs. 

Youmans, J., congenital dislocation of knee, 
768 



THE END, 



50 



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